Healthcare Provider Details

I. General information

NPI: 1730363763
Provider Name (Legal Business Name): UCLA HOSPITAL DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UCLA HOSPITAL DENTISTRY 10833 LE CONTE AVE. CHS BLDG ROOM A0-156B
LOS ANGELES CA
90095-0001
US

IV. Provider business mailing address

P.O. BOX 84582 UCLA HOSPITAL DENTISTRY
LOS ANGELES CA
90073
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-8775
  • Fax: 310-206-4201
Mailing address:
  • Phone: 310-206-8775
  • Fax: 310-206-4210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code284300000X
TaxonomySpecial Hospital
License NumberD19585
License Number StateCA

VIII. Authorized Official

Name: MS. ROSA M. GONZALEZ
Title or Position: OPERATIONS MANAGER
Credential: MSO III
Phone: 310-206-6926