Healthcare Provider Details

I. General information

NPI: 1841055688
Provider Name (Legal Business Name): KOA DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3544 W OLYMPIC BLVD STE 118
LOS ANGELES CA
90019-3529
US

IV. Provider business mailing address

3544 W OLYMPIC BLVD STE 118
LOS ANGELES CA
90019-3529
US

V. Phone/Fax

Practice location:
  • Phone: 323-735-0448
  • Fax: 323-735-4827
Mailing address:
  • Phone: 323-735-0448
  • Fax: 323-735-4827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN YOUNG KANG
Title or Position: PRESIDENT
Credential: DDS
Phone: 951-533-1958