Provider Demographics
NPI:1487023255
Name:MANDEL, EDWARD BRYCE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:BRYCE
Last Name:MANDEL
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LECOM WAY
Mailing Address - Street 2:LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435
Mailing Address - Country:US
Mailing Address - Phone:850-951-0200
Mailing Address - Fax:
Practice Address - Street 1:101 LECOM WAY
Practice Address - Street 2:LAKE ERIE COLLEGE OF OSTEOPATHIC MEDICINE
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435
Practice Address - Country:US
Practice Address - Phone:850-951-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN139781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice