MEDICARE: UCLA FACULTY GROUP DENTAL PRACTICE

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	1223E0200X	Endodontics	277 (SPECIAL PERMIT)	CA

General Provider Information

NPI Number	:	1992163786
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UCLA FACULTY GROUP DENTAL PRACTICE

Provider Business Mailing Address
First Line	:	100 UCLA MEDICAL PLZ STE 350
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-6999
Country	:	US
Telephone Number	:	310-794-5750
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 UCLA MEDICAL PLZ STE 350
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-6999
Country	:	US
Telephone Number	:	310-794-5750
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	ROCHELLE BACHE
Credential	:
Telephone Number	:	310-794-5750

Provider Enumeration Date	:	02/08/2016
Last Update Date	:	02/08/2016

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