Provider Demographics
NPI:1275067704
Name:EDMUNDS, NATHANIEL TODD (DMD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:TODD
Last Name:EDMUNDS
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 1:10884 N SLATE LN
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-4300
Mailing Address - Country:US
Mailing Address - Phone:801-678-9518
Mailing Address - Fax:
Practice Address - Street 1:867 EASTGATE NORTH DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1791
Practice Address - Country:US
Practice Address - Phone:513-843-0133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13421345-99251223S0112X
OH30.0268721223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery