Provider Demographics
NPI:1376641720
Name:UCLA PERIODONTAL CLINIC
Entity Type:Organization
Organization Name:UCLA PERIODONTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:FLAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PIRIH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PHD
Authorized Official - Phone:310-825-6486
Mailing Address - Street 1:10833 LE CONTE AVE
Mailing Address - Street 2:CHS BO 130
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1668
Mailing Address - Country:US
Mailing Address - Phone:310-825-3795
Mailing Address - Fax:310-825-9653
Practice Address - Street 1:UCLA SCHOOL OF DENTISTRY
Practice Address - Street 2:CHS B0 130
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1668
Practice Address - Country:US
Practice Address - Phone:310-825-3795
Practice Address - Fax:310-825-9653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20591223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD34623OtherDENTICAL
CA02059OtherDELTA DENTAL OF CA GROUP