Provider Demographics
NPI:1366022774
Name:EDGEMERE DENTAL PLLC
Entity Type:Organization
Organization Name:EDGEMERE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEL
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:GREENHALGH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:915-921-6200
Mailing Address - Street 1:10510 MONTWOOD DR STE B
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-2717
Mailing Address - Country:US
Mailing Address - Phone:352-443-9151
Mailing Address - Fax:
Practice Address - Street 1:12371 EDGEMERE BLVD STE 206
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-4878
Practice Address - Country:US
Practice Address - Phone:915-921-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty