MEDICARE: UCLA DENTAL CLINICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	G01005	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G01005	OTHER	CA	DENTICAL
2	01005	OTHER	CA	DELTA DENTAL

General Provider Information

NPI Number	:	1740392182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UCLA DENTAL CLINICS

Provider Business Mailing Address
First Line	:	PO BOX 951668
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-1668
Country	:	US
Telephone Number	:	310-825-9805
Fax Number	:	310-825-5252

Provider Business Practice Location Address
First Line	:	10833 LE CONTE AVE
Second Line	:	SUITE 10137 CHS
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-1668
Country	:	US
Telephone Number	:	310-825-9805
Fax Number	:	310-825-5252

Authorized Official
Title or Position	:	DIRECTOR CLINICAL DENTAL CENTER
Name	:	DR. JEFFREY M GOLDSTEIN
Credential	:	PHD MBA
Telephone Number	:	310-794-5565

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	08/22/2020

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Practice Location Address:

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1609881374 — DR. DIANA V. MESSADI D.D.S.
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1316042062 — LEROY VEGO DDS MS
Practice Location Address:

UCLA SCHOOL OF DENTISTRY , 10833 LECONTE AVE 20-140
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Practice Location Address:

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1629161351 — DR. ERIC C. SUNG DDS
Practice Location Address:

UCLA SCHOOL OF DENTISTRY. CHS A0-156 , 10833 LE CONTE AVE.
LOS ANGELES, CA
90095-1668

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Directions to “UCLA DENTAL CLINICS ” Practice Location

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