Provider Demographics
NPI:1245589621
Name:MCDONALD, EDWARD ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ROBERT
Last Name:MCDONALD
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:P.O. BOX 526
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731
Mailing Address - Country:US
Mailing Address - Phone:631-368-8201
Mailing Address - Fax:
Practice Address - Street 1:3 NITA ST.
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731
Practice Address - Country:US
Practice Address - Phone:631-368-8201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026009-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice