Provider Demographics
NPI:1033446026
Name:DRS ETHEREDGE & SCHRY DENTAL
Entity Type:Organization
Organization Name:DRS ETHEREDGE & SCHRY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:ETHEREDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-627-9056
Mailing Address - Street 1:3365 BURNS RD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3365 BURNS RD
Practice Address - Street 2:SUITE 212
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4326
Practice Address - Country:US
Practice Address - Phone:561-627-9056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-11
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL85915OtherBLUE CROSS BLUE SHIELD
FL67658OtherBLUE CROSS BLUE SHIELD