Provider Demographics
NPI:1700978780
Name:UCLA FACULTY GROUP DENTAL PRACTICE
Entity Type:Organization
Organization Name:UCLA FACULTY GROUP DENTAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BACHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-794-5750
Mailing Address - Street 1:100 UCLA MEDICAL PLZ STE 350
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-0001
Mailing Address - Country:US
Mailing Address - Phone:310-794-5750
Mailing Address - Fax:310-208-0786
Practice Address - Street 1:100 UCLA MEDICAL PLZ STE 350
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-794-5750
Practice Address - Fax:310-208-0786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20241223E0200X
CA20211223G0001X, 1223P0221X, 124Q00000X
CA20291223P0700X
CA20261223S0112X
CA20231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Not Answered124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty