Provider Demographics
NPI:1285024372
Name:USC ORAL AND MAXILLOFACIAL FACULTY PRACTICE
Entity Type:Organization
Organization Name:USC ORAL AND MAXILLOFACIAL FACULTY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-740-9648
Mailing Address - Street 1:925 WEST 34TH STREET
Mailing Address - Street 2:SUITE 149
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089
Mailing Address - Country:US
Mailing Address - Phone:213-740-9648
Mailing Address - Fax:
Practice Address - Street 1:925 W 34TH ST
Practice Address - Street 2:SUITE #149
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0058
Practice Address - Country:US
Practice Address - Phone:213-740-9648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty