Provider Demographics
NPI:1407996259
Name:EDWARDS, JEFFREY L (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:EDWARDS
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 1:2134 NICHOLASVILLE RD
Mailing Address - Street 2:#15
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2521
Mailing Address - Country:US
Mailing Address - Phone:859-278-0427
Mailing Address - Fax:859-278-8873
Practice Address - Street 1:2134 NICHOLASVILLE RD
Practice Address - Street 2:#15
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2521
Practice Address - Country:US
Practice Address - Phone:859-278-0427
Practice Address - Fax:859-278-8873
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60056819Medicaid
KY61900320Medicaid