Provider Demographics
NPI:1467920892
Name:EDMONDSON, MALLORY (MSDH, RDH)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:EDMONDSON
Suffix:
Gender:F
Credentials:MSDH, RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 N 600 E
Mailing Address - Street 2:
Mailing Address - City:ROLLING PRAIRIE
Mailing Address - State:IN
Mailing Address - Zip Code:46371-9511
Mailing Address - Country:US
Mailing Address - Phone:219-363-8866
Mailing Address - Fax:
Practice Address - Street 1:1002 S ESTHER ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-1440
Practice Address - Country:US
Practice Address - Phone:219-363-8866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-03
Last Update Date:2018-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13007311A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist