Provider Demographics
NPI:1194936047
Name:DAVIDOV, MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DAVIDOV
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 1:8250 W.3-RD ST.
Mailing Address - Street 2:#201
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4327
Mailing Address - Country:US
Mailing Address - Phone:323-653-0816
Mailing Address - Fax:
Practice Address - Street 1:8250 W 3RD ST
Practice Address - Street 2:SUITE 201
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4327
Practice Address - Country:US
Practice Address - Phone:323-653-0816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50454122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist