Healthcare Provider Details

I. General information

NPI: 1053238220
Provider Name (Legal Business Name): RENAT DAUDOV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18024 VENTURA BLVD
ENCINO CA
91316-3516
US

IV. Provider business mailing address

18024 VENTURA BLVD
ENCINO CA
91316-3516
US

V. Phone/Fax

Practice location:
  • Phone: 747-314-4076
  • Fax:
Mailing address:
  • Phone: 747-314-4076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number113059
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: