Provider Demographics
NPI:1700864527
Name:EDWARD STREET DENTAL
Entity Type:Organization
Organization Name:EDWARD STREET DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-548-6110
Mailing Address - Street 1:707 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-2533
Mailing Address - Country:US
Mailing Address - Phone:248-548-6110
Mailing Address - Fax:248-548-2718
Practice Address - Street 1:707 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-2533
Practice Address - Country:US
Practice Address - Phone:248-548-6110
Practice Address - Fax:248-548-2718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171101223G0001X
MI135301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty