Basic Information
| Provider Information | |||||||||
| NPI: | 1649305624 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINGDENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 646 N LARCHMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900041308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234648677 | ||||||||
| FaxNumber: | 3234634692 | ||||||||
| Practice Location | |||||||||
| Address1: | 7349 TOPANGA CANYON BLVD | ||||||||
| Address2: | |||||||||
| City: | CANOGA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913031244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183481506 | ||||||||
| FaxNumber: | 8183484883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 09/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | GILBERT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8183481506 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 36463 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 36463 | 01 | CA | LICENCE NUMBER | OTHER | G3983-02 | 01 | CA | DENTI-CAL | OTHER | 36423 | 01 | CA | LICENCE # | OTHER |