Provider Demographics
NPI:1467594069
Name:EDWARDS, WALTER G JR (D D S)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:G
Last Name:EDWARDS
Suffix:JR
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 LINCOLN AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-3418
Mailing Address - Country:US
Mailing Address - Phone:914-235-1200
Mailing Address - Fax:914-235-1256
Practice Address - Street 1:33 LINCOLN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-3418
Practice Address - Country:US
Practice Address - Phone:914-235-1200
Practice Address - Fax:914-235-1256
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0377931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00836686Medicaid