Healthcare Provider Details

I. General information

NPI: 1255465902
Provider Name (Legal Business Name): UCLA VENICE DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 LINCOLN BLVD
VENICE CA
90291-2842
US

IV. Provider business mailing address

10833 LE CONTE AVE CHS 33-019
LOS ANGELES CA
90095-1668
US

V. Phone/Fax

Practice location:
  • Phone: 310-392-4103
  • Fax:
Mailing address:
  • Phone: 310-825-4855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. MARC HAYASETI
Title or Position: ASSOCIATE CLINICAL PROFESSOR
Credential: DDS
Phone: 310-825-4855