Provider Demographics
NPI:1558445221
Name:MICHAEL Q EDWARDS DMD PC
Entity Type:Organization
Organization Name:MICHAEL Q EDWARDS DMD PC
Other - Org Name:OPTIMA DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:Q
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:636-583-2612
Mailing Address - Street 1:124 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MO
Mailing Address - Zip Code:63084
Mailing Address - Country:US
Mailing Address - Phone:636-583-2612
Mailing Address - Fax:636-583-6479
Practice Address - Street 1:124 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084
Practice Address - Country:US
Practice Address - Phone:636-583-2612
Practice Address - Fax:636-583-6479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE015747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015747OtherDELTA DENTAL PLAN