Healthcare Provider Details

I. General information

NPI: 1104912377
Provider Name (Legal Business Name): JOSE CARLOS DAUDT POLIDO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD MS# 116
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

6430 W SUNSET BLVD SUITE 600
LOS ANGELES CA
90028-7901
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2130
  • Fax: 323-361-1090
Mailing address:
  • Phone: 323-361-4116
  • Fax: 323-361-1090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number39870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: