=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740851617
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COPPELSON DENTAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2021
-----------------------------------------------------
Last Update Date | 07/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10921 WILSHIRE BLVD STE 912
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-3906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-579-9710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10921 WILSHIRE BLVD STE 912
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-3906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-579-9710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KEVIN COPPELSON
-----------------------------------------------------
Credential | M.D., D.D.S.
-----------------------------------------------------
Telephone | 310-579-9710
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------