Healthcare Provider Details

I. General information

NPI: 1568897155
Provider Name (Legal Business Name): WESTSIDE ENDODONTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2013
Last Update Date: 09/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2990 S SEPULVEDA BLVD #304
LOS ANGELES CA
90064-0002
US

IV. Provider business mailing address

2990 S SEPULVEDA BLVD #304
LOS ANGELES CA
90064-0002
US

V. Phone/Fax

Practice location:
  • Phone: 310-575-4143
  • Fax: 310-575-4092
Mailing address:
  • Phone: 310-575-4143
  • Fax: 310-575-4092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number45489
License Number StateCA

VIII. Authorized Official

Name: DR. KWOR LOO
Title or Position: OWNER
Credential: DDS
Phone: 310-575-4143