Provider Demographics
NPI:1487656377
Name:EDELSON, DAVID R (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:EDELSON
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 1:92 EAST ST
Mailing Address - Street 2:
Mailing Address - City:PLAINVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06062-2302
Mailing Address - Country:US
Mailing Address - Phone:860-747-1004
Mailing Address - Fax:860-793-2219
Practice Address - Street 1:92 EAST ST
Practice Address - Street 2:
Practice Address - City:PLAINVILLE
Practice Address - State:CT
Practice Address - Zip Code:06062-2302
Practice Address - Country:US
Practice Address - Phone:860-747-1004
Practice Address - Fax:860-793-2219
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-05-03
Provider Licenses
StateLicense IDTaxonomies
CT0063991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice