Healthcare Provider Details

I. General information

NPI: 1922514819
Provider Name (Legal Business Name): LARCHMONT VILLAGE DENTAL SPECIALTY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2017
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N LARCHMONT BLVD STE 721
LOS ANGELES CA
90004-6407
US

IV. Provider business mailing address

321 N LARCHMONT BLVD STE 721
LOS ANGELES CA
90004-6407
US

V. Phone/Fax

Practice location:
  • Phone: 323-465-3116
  • Fax:
Mailing address:
  • Phone: 323-465-3116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDDS45489
License Number StateCA

VIII. Authorized Official

Name: DR. KWOR CHIEH LOO
Title or Position: OWNER
Credential: DDS
Phone: 626-475-7424