Provider Demographics
NPI:1124238910
Name:UC REGENTS OF THE UNIVERSITY OF MAXILLOFACIAL
Entity type:Organization
Organization Name:UC REGENTS OF THE UNIVERSITY OF MAXILLOFACIAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROFESSOR
Authorized Official - Prefix:
Authorized Official - First Name:ELENI
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROUMANAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-794-9858
Mailing Address - Street 1:10833 LE CONTE AVE # A0-0156
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1668
Mailing Address - Country:US
Mailing Address - Phone:310-206-6926
Mailing Address - Fax:310-206-4201
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:BOX 951668
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1668
Practice Address - Country:US
Practice Address - Phone:310-794-9858
Practice Address - Fax:310-206-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374891223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWD37489Medicare UPIN