Provider Demographics
NPI:1104912377
Name:POLIDO, JOSE CARLOS DAUDT (DDS)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:CARLOS DAUDT
Last Name:POLIDO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6430 W SUNSET BLVD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7901
Mailing Address - Country:US
Mailing Address - Phone:323-361-4116
Mailing Address - Fax:323-361-1090
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MS# 116
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-2130
Practice Address - Fax:323-361-1090
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA398701223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD39870Medicaid