Provider Demographics
NPI:1285771378
Name:REGENTS OF THE UNIVERSITY OF UCLA MAXILLOFACIAL PROSTHODONTICS
Entity type:Organization
Organization Name:REGENTS OF THE UNIVERSITY OF UCLA MAXILLOFACIAL PROSTHODONTICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:C
Authorized Official - Last Name:SUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-206-6407
Mailing Address - Street 1:10833 LE CONTE AVE RM AO-156A
Mailing Address - Street 2:BOX 951668
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-3075
Mailing Address - Country:US
Mailing Address - Phone:310-825-6510
Mailing Address - Fax:310-206-4201
Practice Address - Street 1:10833 LE CONTE AVE RM AO-156A CHS
Practice Address - Street 2:BOX 951668
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:310-825-6510
Practice Address - Fax:310-206-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA383701223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91297Medicaid
CAG91297Medicaid
CAG91297Medicaid