Healthcare Provider Details

I. General information

NPI: 1376641720
Provider Name (Legal Business Name): UCLA PERIODONTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UCLA SCHOOL OF DENTISTRY CHS B0 130
LOS ANGELES CA
90095-1668
US

IV. Provider business mailing address

10833 LE CONTE AVE CHS BO 130
LOS ANGELES CA
90095-1668
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-3795
  • Fax: 310-825-9653
Mailing address:
  • Phone: 310-825-3795
  • Fax: 310-825-9653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2059
License Number StateCA

VIII. Authorized Official

Name: DR. FLAVIA PIRIH
Title or Position: CHAIR
Credential: DDS, PHD
Phone: 310-825-6486