Provider Demographics
NPI:1417119306
Name:JEFFREY L. EDWARDS, DMD PSC
Entity Type:Organization
Organization Name:JEFFREY L. EDWARDS, DMD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-278-0427
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5681122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60056819Medicaid