Provider Demographics
NPI:1083703763
Name:EDWARDS, MARK TODD (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TODD
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 1:6000 JFH PARKWAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:ADAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30103
Mailing Address - Country:US
Mailing Address - Phone:770-773-7244
Mailing Address - Fax:770-773-3727
Practice Address - Street 1:6000 JFH PARKWAY
Practice Address - Street 2:SUITE A
Practice Address - City:ADAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30103
Practice Address - Country:US
Practice Address - Phone:770-773-7244
Practice Address - Fax:770-773-3727
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA010676122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist