Healthcare Provider Details

I. General information

NPI: 1821209776
Provider Name (Legal Business Name): GRANT A LOOSVELT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2080 CENTURY PARK E SUITE 1601
LOS ANGELES CA
90067-2001
US

IV. Provider business mailing address

2080 CENTURY PARK E SUITE 1601
LOS ANGELES CA
90067-2001
US

V. Phone/Fax

Practice location:
  • Phone: 310-277-5678
  • Fax: 310-277-3294
Mailing address:
  • Phone: 310-277-5678
  • Fax: 310-277-3294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number47389
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: