Healthcare Provider Details

I. General information

NPI: 1063630267
Provider Name (Legal Business Name): UCLA GRAD ENDO CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10833 LE CONTE AVE SUITE 30-125 CHS
LOS ANGELES CA
90095-1668
US

IV. Provider business mailing address

10833 LE CONTE AVE. CHS 43-007
LOS ANGELES CA
90095-1668
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-4348
  • Fax: 310-206-5030
Mailing address:
  • Phone: 310-825-8048
  • Fax: 310-206-5030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD51343
License Number StateCA

VIII. Authorized Official

Name: DR. MO KWAN KANG
Title or Position: ASSOC. PROFESSOR
Credential: DDS
Phone: 310-825-8048