MEDICARE: KINGDENTAL

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	1223G0001X	General Practice Dentistry	36463	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	36463	OTHER	CA	LICENCE NUMBER
2	G3983-02	OTHER	CA	DENTI-CAL
3	36423	OTHER	CA	LICENCE #

General Provider Information

NPI Number	:	1649305624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINGDENTAL

Provider Business Mailing Address
First Line	:	646 N LARCHMONT BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-1308
Country	:	US
Telephone Number	:	323-464-8677
Fax Number	:	323-463-4692

Provider Business Practice Location Address
First Line	:	7349 TOPANGA CANYON BLVD
Second Line	:
City	:	CANOGA PARK
State	:	CA
Zip	:	91303-1244
Country	:	US
Telephone Number	:	818-348-1506
Fax Number	:	818-348-4883

Authorized Official
Title or Position	:	CEO
Name	:	DR. GILBERT L KING
Credential	:	DDS
Telephone Number	:	818-348-1506

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	09/20/2016

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Directions to “KINGDENTAL ” Practice Location

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