Provider Demographics
NPI:1730672510
Name:JEREMY EDWARDS DDS PLLC
Entity Type:Organization
Organization Name:JEREMY EDWARDS DDS PLLC
Other - Org Name:OKLAHOMA DENTAL IMPLANTS AND ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING DEPARTMENT
Authorized Official - Prefix:
Authorized Official - First Name:THAO
Authorized Official - Middle Name:T
Authorized Official - Last Name:VO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-848-7974
Mailing Address - Street 1:3000 UNITED FOUNDERS BLVD STE 237
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4334
Mailing Address - Country:US
Mailing Address - Phone:405-848-7974
Mailing Address - Fax:405-848-0033
Practice Address - Street 1:1004 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3025
Practice Address - Country:US
Practice Address - Phone:405-348-8184
Practice Address - Fax:405-348-5349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK65861223S0112X
1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty