Provider Demographics
NPI:1295837284
Name:EDGE, MARION JACKSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARION
Middle Name:JACKSON
Last Name:EDGE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIVERSITY OF LOUISVILLE SCHOOL OF DENTISTRY
Mailing Address - Street 2:501 S. PRESTON ST.
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40292-0001
Mailing Address - Country:US
Mailing Address - Phone:502-852-5128
Mailing Address - Fax:502-852-7163
Practice Address - Street 1:UNIVERSITY OF LOUISVILLE SCHOOL OF DENTISTRY
Practice Address - Street 2:501 S. PRESTON ST.
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40292-0001
Practice Address - Country:US
Practice Address - Phone:502-852-5128
Practice Address - Fax:502-852-7163
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39561223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9181733OtherDORAL