Provider Demographics
NPI:1285858431
Name:EDWARDS, CORY BLAKE (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:BLAKE
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 NARROWS WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242
Mailing Address - Country:US
Mailing Address - Phone:205-981-9100
Mailing Address - Fax:205-995-3762
Practice Address - Street 1:1063 NARROWS WAY
Practice Address - Street 2:SUITE B
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242
Practice Address - Country:US
Practice Address - Phone:205-981-9100
Practice Address - Fax:205-995-3762
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL52171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515 37373OtherBLUECROSS BLUESHIELD