Provider Demographics
NPI:1982738639
Name:UCLA SCHOOL OF DENTISTRY
Entity Type:Organization
Organization Name:UCLA SCHOOL OF DENTISTRY
Other - Org Name:AEGD
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,MBA
Authorized Official - Phone:310-794-5565
Mailing Address - Street 1:10833 LE CONTE AVE
Mailing Address - Street 2:#33-039 CHS
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1668
Mailing Address - Country:US
Mailing Address - Phone:310-825-6672
Mailing Address - Fax:310-794-7964
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:#33-039 CHS
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1668
Practice Address - Country:US
Practice Address - Phone:310-825-6672
Practice Address - Fax:310-794-7964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD461821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty