Provider Demographics
NPI:1063630267
Name:UCLA GRAD ENDO CLINIC
Entity Type:Organization
Organization Name:UCLA GRAD ENDO CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MO
Authorized Official - Middle Name:KWAN
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-825-4348
Mailing Address - Street 1:10833 LE CONTE AVE
Mailing Address - Street 2:SUITE 30-125 CHS
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1668
Mailing Address - Country:US
Mailing Address - Phone:310-825-4348
Mailing Address - Fax:310-206-5030
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:SUITE 30-125 CHS
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1668
Practice Address - Country:US
Practice Address - Phone:310-825-4348
Practice Address - Fax:310-206-5030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD513431223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG01005-01Medicaid