Provider Demographics
NPI:1629670419
Name:DOLGOV, DMITRY VLADIMIR (DMD)
Entity Type:Individual
Prefix:
First Name:DMITRY
Middle Name:VLADIMIR
Last Name:DOLGOV
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463 S REXFORD DR APT 302
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-4750
Mailing Address - Country:US
Mailing Address - Phone:614-551-1990
Mailing Address - Fax:
Practice Address - Street 1:1304 15TH ST STE 209
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1811
Practice Address - Country:US
Practice Address - Phone:310-395-1810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1057951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice