Provider Demographics
NPI:1619985371
Name:EDMONDS, RICHARD BROOK (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:BROOK
Last Name:EDMONDS
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 1:806 16TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1818
Mailing Address - Country:US
Mailing Address - Phone:580-223-5514
Mailing Address - Fax:580-223-5908
Practice Address - Street 1:806 16TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1818
Practice Address - Country:US
Practice Address - Phone:580-223-5514
Practice Address - Fax:580-223-5908
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK47551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice