Provider Demographics
NPI:1225024938
Name:MEYDRECH, EDWARD A (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:A
Last Name:MEYDRECH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 STUART RD NE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-4992
Mailing Address - Country:US
Mailing Address - Phone:423-559-0157
Mailing Address - Fax:423-559-1058
Practice Address - Street 1:430 STUART RD NE
Practice Address - Street 2:SUITE 1
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4992
Practice Address - Country:US
Practice Address - Phone:423-559-0157
Practice Address - Fax:423-559-1058
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS78031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0009949Medicaid