Provider Demographics
NPI:1689858623
Name:UCLA GRADUATE PROSTHODONTICS
Entity Type:Organization
Organization Name:UCLA GRADUATE PROSTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MSO III
Authorized Official - Phone:310-206-6926
Mailing Address - Street 1:P.O. BOX 84582
Mailing Address - Street 2:UCLA GRADUATE PROSTHODONTICS
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90073
Mailing Address - Country:US
Mailing Address - Phone:310-206-8775
Mailing Address - Fax:310-206-4201
Practice Address - Street 1:UCLA GRADUATE PROSTHODONTICS
Practice Address - Street 2:10833 LE CONTE AVE. CHS BLDG. ROOM A0-156B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-206-8775
Practice Address - Fax:310-206-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD19585284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital