Provider Demographics
NPI:1063629236
Name:EDZIAK, MICHAEL FRANCIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:FRANCIS
Last Name:EDZIAK
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 1:127 HOSPITAL DR STE 204
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2500
Mailing Address - Country:US
Mailing Address - Phone:707-642-4403
Mailing Address - Fax:707-642-0844
Practice Address - Street 1:150 HOSPITAL DR.
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589
Practice Address - Country:US
Practice Address - Phone:707-642-4403
Practice Address - Fax:707-642-0844
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD221481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice