Provider Demographics
NPI:1003220039
Name:EDWARDS, JEREMY ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ALAN
Last Name:EDWARDS
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 1:1004 MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3025
Mailing Address - Country:US
Mailing Address - Phone:405-348-8184
Mailing Address - Fax:405-348-5349
Practice Address - Street 1:1004 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3025
Practice Address - Country:US
Practice Address - Phone:405-348-8184
Practice Address - Fax:405-348-5349
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK65861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program