Healthcare Provider Details

I. General information

NPI: 1659181717
Provider Name (Legal Business Name): NUGENT BARDI III DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2025
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14444 VENTURA BLVD
SHERMAN OAKS CA
91423-2607
US

IV. Provider business mailing address

3663 TORRANCE BLVD STE 3
TORRANCE CA
90503-7814
US

V. Phone/Fax

Practice location:
  • Phone: 818-849-6756
  • Fax:
Mailing address:
  • Phone: 310-791-0666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: HAREEM KIM
Title or Position: ADMINISTRATOR
Credential:
Phone: 619-254-8656