Provider Demographics
NPI:1124542139
Name:EDGEWOOD DENTAL, LLP
Entity Type:Organization
Organization Name:EDGEWOOD DENTAL, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAUGHTINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:219-872-2110
Mailing Address - Street 1:3008 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360
Mailing Address - Country:US
Mailing Address - Phone:219-872-2110
Mailing Address - Fax:
Practice Address - Street 1:3008 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-4636
Practice Address - Country:US
Practice Address - Phone:219-872-2110
Practice Address - Fax:219-872-1082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
120093541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1053411645OtherPROVIDER NPI
IN100376490BMedicaid
IN1245390236OtherPROVIDER NPI