Provider Demographics
NPI:1639198021
Name:EDWARDS, JAMES ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ROBERT
Last Name:EDWARDS
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 1:1172 FALLBROOK ST
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-3620
Mailing Address - Country:US
Mailing Address - Phone:916-599-2676
Mailing Address - Fax:503-929-2033
Practice Address - Street 1:2167 LINCOLN WAY
Practice Address - Street 2:UNIT 40
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632
Practice Address - Country:US
Practice Address - Phone:209-744-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD75341223G0001X
CA102278122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR161722649OtherTAX IDENTIFICATION NUMBER