Healthcare Provider Details

I. General information

NPI: 1356476865
Provider Name (Legal Business Name): REGENTS OF UNIVERSITY OF CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

10833 LE CONTE AVE CHS 10 -165
LOS ANGELES CA
90095-1668
US

IV. Provider business mailing address

10833 LE CONTE AVE. CHS 53-068
LOS ANGELES CA
90095-1668
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-5634
  • Fax: 310-206-2748
Mailing address:
  • Phone: 310-825-1689
  • Fax: 310-825-7232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. SANJAY MALLYA
Title or Position: PROFESSOR
Credential: DDS
Phone: 310-825-1689