=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285313437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR EDWIN POULDAR DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2023
-----------------------------------------------------
Last Update Date | 07/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14912 BURBANK BLVD
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91411-3609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-909-0222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14912 BURBANK BLVD
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91411-3609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-909-0222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | EDWIN JAKOB POULDAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-780-1187
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------