Provider Demographics
NPI:1295360428
Name:DJ EDGERLE, DDS, PC
Entity Type:Organization
Organization Name:DJ EDGERLE, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEFOE
Authorized Official - Middle Name:J
Authorized Official - Last Name:EDGERLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-949-2720
Mailing Address - Street 1:751 KENMOOR AVE SE STE G
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2391
Mailing Address - Country:US
Mailing Address - Phone:616-949-2720
Mailing Address - Fax:
Practice Address - Street 1:751 KENMOOR AVE SE STE G
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2391
Practice Address - Country:US
Practice Address - Phone:616-949-2720
Practice Address - Fax:616-949-9320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty