Provider Demographics
NPI:1598357923
Name:EDGERLEY DENTAL LLC
Entity Type:Organization
Organization Name:EDGERLEY DENTAL LLC
Other - Org Name:CHESTERFIELD WOODLAKE DENTAL AND PROSTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROSTHODONTIST/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:EDGERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MDS
Authorized Official - Phone:314-878-8880
Mailing Address - Street 1:14377 WOODLAKE DR STE 206
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5735
Mailing Address - Country:US
Mailing Address - Phone:314-878-8880
Mailing Address - Fax:
Practice Address - Street 1:14377 WOODLAKE DR STE 206
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5735
Practice Address - Country:US
Practice Address - Phone:314-878-8880
Practice Address - Fax:314-658-9940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-08
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty