Provider Demographics
NPI:1639456395
Name:STURDIVANT, EDWARD CLARK (DDS)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:CLARK
Last Name:STURDIVANT
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 1:1119 LAWRENCE STREET
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-2224
Mailing Address - Country:US
Mailing Address - Phone:360-385-5121
Mailing Address - Fax:360-379-9534
Practice Address - Street 1:1119 LAWRENCE STREET
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2224
Practice Address - Country:US
Practice Address - Phone:360-385-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00004262122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist