MEDICARE: UCLA PERIODONTAL CLINIC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	2059	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D34623	OTHER	CA	DENTICAL
2	02059	OTHER	CA	DELTA DENTAL OF CA GROUP

General Provider Information

NPI Number	:	1376641720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UCLA PERIODONTAL CLINIC

Provider Business Mailing Address
First Line	:	10833 LE CONTE AVE
Second Line	:	CHS BO 130
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-1668
Country	:	US
Telephone Number	:	310-825-3795
Fax Number	:	310-825-9653

Provider Business Practice Location Address
First Line	:	UCLA SCHOOL OF DENTISTRY
Second Line	:	CHS B0 130
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-1668
Country	:	US
Telephone Number	:	310-825-3795
Fax Number	:	310-825-9653

Authorized Official
Title or Position	:	CHAIR
Name	:	DR. FLAVIA PIRIH
Credential	:	DDS, PHD
Telephone Number	:	310-825-6486

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	05/10/2021

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10833 LE CONTE AVE , CHS 10-165
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1609881374 — DR. DIANA V. MESSADI D.D.S.
Practice Location Address:

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1679580575 — DR. STUART C. WHITE DDS
Practice Location Address:

10833 LE CONTE AVE. CHS 10-165
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1740392182 — UCLA DENTAL CLINICS
Practice Location Address:

10833 LE CONTE AVE , SUITE 10137 CHS
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1316042062 — LEROY VEGO DDS MS
Practice Location Address:

UCLA SCHOOL OF DENTISTRY , 10833 LECONTE AVE 20-140
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90095-1668

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1629161351 — DR. ERIC C. SUNG DDS
Practice Location Address:

UCLA SCHOOL OF DENTISTRY. CHS A0-156 , 10833 LE CONTE AVE.
LOS ANGELES, CA
90095-1668

Practice Phone: 310-825-5889
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Directions to “UCLA PERIODONTAL CLINIC ” Practice Location

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