Healthcare Provider Details

I. General information

NPI: 1740065788
Provider Name (Legal Business Name): KOMAL KHULLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 S VERMONT AVE STE 210
LOS ANGELES CA
90004-5955
US

IV. Provider business mailing address

132 S VERMONT AVE STE 210
LOS ANGELES CA
90004-5955
US

V. Phone/Fax

Practice location:
  • Phone: 213-389-2625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113775
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: