Provider Demographics
NPI:1023185006
Name:EDMONDSON, JON (DDS)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:
Last Name:EDMONDSON
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 1:3100 LORD BALTIMORE DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2879
Mailing Address - Country:US
Mailing Address - Phone:410-944-9090
Mailing Address - Fax:410-944-5119
Practice Address - Street 1:3100 LORD BALTIMORE DR
Practice Address - Street 2:SUITE 210
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-2879
Practice Address - Country:US
Practice Address - Phone:410-944-9090
Practice Address - Fax:410-944-5119
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD111461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice