Provider Demographics
NPI:1588086359
Name:TERRY, EDWARD
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:TERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1769 LEXINGTON AVE N # 104
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:703-535-1583
Practice Address - Street 1:2 E GLEBE RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22305-2938
Practice Address - Country:US
Practice Address - Phone:703-535-5568
Practice Address - Fax:703-535-1583
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402206182124Q00000X
MND180125K00000X, 125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
No124Q00000XDental ProvidersDental Hygienist
No125K00000XDental ProvidersAdvanced Practice Dental Therapist