Provider Demographics
NPI:1801403886
Name:POULDAR, EDWIN JAKOB (DDS)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:JAKOB
Last Name:POULDAR
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 1:14912 BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-3609
Mailing Address - Country:US
Mailing Address - Phone:818-909-0222
Mailing Address - Fax:
Practice Address - Street 1:14912 BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91411-3609
Practice Address - Country:US
Practice Address - Phone:818-909-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2023-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105565122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist