Healthcare Provider Details

I. General information

NPI: 1336177955
Provider Name (Legal Business Name): CONRAD J. SACK D.M.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 W SUNSET BLVD SUITE 200
LOS ANGELES CA
90069-3701
US

IV. Provider business mailing address

9201 SUNSET BLVD. #200 SUITE 200
LOS ANGELES CA
90069
US

V. Phone/Fax

Practice location:
  • Phone: 310-273-5775
  • Fax: 310-275-5454
Mailing address:
  • Phone: 310-273-5775
  • Fax: 310-275-5454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDL032172
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: