Healthcare Provider Details

I. General information

NPI: 1396674081
Provider Name (Legal Business Name): SAGE KELNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8540 S SEPULVEDA BLVD STE 1102
LOS ANGELES CA
90045-3831
US

IV. Provider business mailing address

1145 BARRY AVE APT 215
LOS ANGELES CA
90049-6234
US

V. Phone/Fax

Practice location:
  • Phone: 310-641-6369
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number110583
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: