MEDICARE: LA CENTER FOR ORAL & MAXIOLLOFACIAL SURGERY A CA GP

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	A97977	CA
2	208600000X	Surgery Physician	A97977	CA

General Provider Information

NPI Number	:	1952672107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA CENTER FOR ORAL & MAXIOLLOFACIAL SURGERY A CA GP

Provider Business Mailing Address
First Line	:	2080 CENTURY PARK E STE 610
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90067-2009
Country	:	US
Telephone Number	:	310-914-9150
Fax Number	:	310-914-9705

Provider Business Practice Location Address
First Line	:	2080 CENTURY PARK E STE 610
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90067-2009
Country	:	US
Telephone Number	:	310-914-9150
Fax Number	:	310-914-9705

Authorized Official
Title or Position	:	MEDICAL DOCTOR
Name	:	DR. STEVEN KUPFERMAN
Credential	:	M.D.
Telephone Number	:	310-914-9150

Provider Enumeration Date	:	01/19/2012
Last Update Date	:	01/19/2012

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