Provider Demographics
NPI:1093750630
Name:TARVER, EDWARD JORDAN IV (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JORDAN
Last Name:TARVER
Suffix:IV
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1111 PARKWAY FRONTAGE RD N
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803
Mailing Address - Country:US
Mailing Address - Phone:863-644-2408
Mailing Address - Fax:
Practice Address - Street 1:1111 PARKWAY FRONTAGE RD N
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803
Practice Address - Country:US
Practice Address - Phone:863-644-2408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN171951223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN17195OtherLICENSE NUMBER
FLBT 9412785OtherDEA