Provider Demographics
NPI:1700025210
Name:GOLOM, EDWARD STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:STEVEN
Last Name:GOLOM
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 1:8336 ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOW SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60480-1468
Mailing Address - Country:US
Mailing Address - Phone:708-839-9636
Mailing Address - Fax:
Practice Address - Street 1:8336 ARCHER AVE
Practice Address - Street 2:
Practice Address - City:WILLOW SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60480-1468
Practice Address - Country:US
Practice Address - Phone:708-839-9636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-08
Last Update Date:2009-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.015546122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist