Provider Demographics
NPI:1225439110
Name:EDWARDS, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E 17TH ST OFC 1
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3607
Mailing Address - Country:US
Mailing Address - Phone:347-903-7277
Mailing Address - Fax:
Practice Address - Street 1:201 E 17TH ST OFC 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3607
Practice Address - Country:US
Practice Address - Phone:347-903-7277
Practice Address - Fax:347-803-1838
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856795122300000X
TX30345122300000X
NY0601421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist