Provider Demographics
NPI:1003920174
Name:EDLIN, MICHAEL JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:EDLIN
Suffix:JR
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 1:8000 BONHOMME AVE.
Mailing Address - Street 2:SUITE 306
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63105
Mailing Address - Country:US
Mailing Address - Phone:314-863-2222
Mailing Address - Fax:314-863-5225
Practice Address - Street 1:8000 BONHOMME AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63105-3515
Practice Address - Country:US
Practice Address - Phone:314-863-2222
Practice Address - Fax:314-863-5225
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO149661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice