Provider Demographics
NPI:1225322019
Name:COPPELSON, KEVIN (DDS, MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:COPPELSON
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10921 WILSHIRE BLVD STE 912
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3906
Mailing Address - Country:US
Mailing Address - Phone:310-579-9710
Mailing Address - Fax:
Practice Address - Street 1:10921 WILSHIRE BLVD STE 912
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024
Practice Address - Country:US
Practice Address - Phone:310-579-9710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX346071223S0112X, 204E00000X
CA157675204E00000X
390200000X
CA1010771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program