1285771378 NPI number — REGENTS OF THE UNIVERSITY OF UCLA MAXILLOFACIAL PROSTHODONTICS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285771378 NPI number — REGENTS OF THE UNIVERSITY OF UCLA MAXILLOFACIAL PROSTHODONTICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REGENTS OF THE UNIVERSITY OF UCLA MAXILLOFACIAL PROSTHODONTICS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285771378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10833 LE CONTE AVE RM AO-156A
Provider Second Line Business Mailing Address:
BOX 951668
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90095-3075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-825-6510
Provider Business Mailing Address Fax Number:
310-206-4201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10833 LE CONTE AVE RM AO-156A CHS
Provider Second Line Business Practice Location Address:
BOX 951668
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90095-3075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-825-6510
Provider Business Practice Location Address Fax Number:
310-206-4201
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SUNG
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
C
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
310-206-6407

Provider Taxonomy Codes

  • Taxonomy code: 1223P0700X , with the licence number:  38370 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G91297 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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