MEDICARE: WPD DENTAL GROUP

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	30416	CA

General Provider Information

NPI Number	:	1982002002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WPD DENTAL GROUP

Provider Business Mailing Address
First Line	:	3700 WILSHIRE BLVD STE 780
Second Line	:	STE780
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3001
Country	:	US
Telephone Number	:	213-380-7900
Fax Number	:

Provider Business Practice Location Address
First Line	:	3700 WILSHIRE BLVD STE 780
Second Line	:	STE780
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-3001
Country	:	US
Telephone Number	:	213-380-7900
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE OFFICER
Name	:	DR. THOMAS J HAN
Credential	:
Telephone Number	:	213-380-7900

Provider Enumeration Date	:	12/06/2014
Last Update Date	:	12/06/2014

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