Provider Demographics
NPI:1497169759
Name:UNIVERSITY OF SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:UNIVERSITY OF SOUTHERN CALIFORNIA
Other - Org Name:HERMAN OSTROW SCHOOL OF DENTISTRY MOBILE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CLINICAL FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-740-7405
Mailing Address - Street 1:1149 S HILL ST
Mailing Address - Street 2:SUITE H550
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-2212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1149 S HILL ST
Practice Address - Street 2:SUITE H550
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-2212
Practice Address - Country:US
Practice Address - Phone:213-740-7405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-16
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD536531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU90595Medicaid