Provider Demographics
NPI:1174684120
Name:EDGERLE, DEFOE JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:DEFOE
Middle Name:JAMES
Last Name:EDGERLE
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 1:751 KENMOOR AVE SE
Mailing Address - Street 2:SUITE G
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2388
Mailing Address - Country:US
Mailing Address - Phone:616-949-4272
Mailing Address - Fax:616-949-9320
Practice Address - Street 1:751 KENMOOR AVE SE
Practice Address - Street 2:SUITE G
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2388
Practice Address - Country:US
Practice Address - Phone:616-949-4272
Practice Address - Fax:616-949-9320
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0159451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice