Provider Demographics
NPI:1497727754
Name:EDMONDSON, C.W. URIAH (DDS)
Entity Type:Individual
Prefix:DR
First Name:C.W.
Middle Name:URIAH
Last Name:EDMONDSON
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 1:170 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21536-1383
Mailing Address - Country:US
Mailing Address - Phone:301-895-5780
Mailing Address - Fax:
Practice Address - Street 1:170 MILLER ST
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21536-1383
Practice Address - Country:US
Practice Address - Phone:301-895-5780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD138211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD039320700Medicaid
WV3810021389Medicaid