Provider Demographics
NPI:1609914209
Name:EDWARDS, JAMES B
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:B
Last Name:EDWARDS
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 1:605 COATE CT
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-3866
Mailing Address - Country:US
Mailing Address - Phone:626-791-8562
Mailing Address - Fax:
Practice Address - Street 1:15188 N 75TH AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4723
Practice Address - Country:US
Practice Address - Phone:623-776-9696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA443941223S0112X
AZ55981223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery