Provider Demographics
NPI:1477546570
Name:EDWARDS, STAN EDWIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:STAN
Middle Name:EDWIN
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1585 SW MARLOW AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5178
Mailing Address - Country:US
Mailing Address - Phone:503-297-7231
Mailing Address - Fax:503-291-1335
Practice Address - Street 1:1585 SW MARLOW AVE STE 220
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5178
Practice Address - Country:US
Practice Address - Phone:503-297-7231
Practice Address - Fax:503-291-1335
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000093701223G0001X
ORD87331223G0001X
NMDD27531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice