Provider Demographics
NPI:1467459438
Name:MUTH, EDWARD ALAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ALAN
Last Name:MUTH
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 1:315 OXFORD ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5249
Mailing Address - Country:US
Mailing Address - Phone:503-362-3723
Mailing Address - Fax:503-364-7515
Practice Address - Street 1:315 OXFORD ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5249
Practice Address - Country:US
Practice Address - Phone:503-362-3723
Practice Address - Fax:503-364-7515
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR47561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR125724Medicaid