MEDICARE: UNIVERSITY OF SOUTHERN CALIFORNIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	122300000X	Dentist
2	1223E0200X	Endodontics
3	1223P0106X	Oral and Maxillofacial Pathology Dentistry
4	1223P0221X	Pediatric Dentistry
5	1223P0300X	Periodontics
6	1223P0700X	Prosthodontics
7	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
8	1223X0008X	Oral and Maxillofacial Radiology Dentistry
9	124Q00000X	Dental Hygienist
10	126800000X	Dental Assistant
11	126900000X	Dental Laboratory Technician
12	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9117717	OTHER	CA	UNITED CONCORDIA
2	ZZZ34010Z	OTHER	CA	BLUE CROSS
3	ZZZ34010Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1285707158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY OF SOUTHERN CALIFORNIA

Provider Business Mailing Address
First Line	:	3151 S HOOVER ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-0641
Country	:	US
Telephone Number	:	213-740-2012
Fax Number	:	213-740-2722

Provider Business Practice Location Address
First Line	:	3151 S HOOVER ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90089-0641
Country	:	US
Telephone Number	:	213-740-2012
Fax Number	:	213-740-2722

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT, ADMINISTRATI
Name	:	MR. TODD DICKEY
Credential	:
Telephone Number	:	213-740-8184

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	03/04/2010

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Directions to “UNIVERSITY OF SOUTHERN CALIFORNIA ” Practice Location

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