Basic Information
| Provider Information | |||||||||
| NPI: | 1740323401 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINGDENTAL | ||||||||
| LastName: | |||||||||
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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: | 646 N LARCHMONT BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900041308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234648677 | ||||||||
| FaxNumber: | 3234634692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | GILBERT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3234648677 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DENTIST | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 3600141 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | G9398302 | 01 | CA | DENTI-CAL | OTHER | G9398301 | 01 | CA | DENTI-CAL | OTHER |