Provider Demographics
NPI:1760827380
Name:EDWARDS & KETCHER, PLLC
Entity Type:Organization
Organization Name:EDWARDS & KETCHER, PLLC
Other - Org Name:ELMA FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-861-8318
Mailing Address - Street 1:PO BOX 1309
Mailing Address - Street 2:410 W MAIN ST
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-1309
Mailing Address - Country:US
Mailing Address - Phone:360-861-8318
Mailing Address - Fax:360-861-8539
Practice Address - Street 1:410 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:WA
Practice Address - Zip Code:98541
Practice Address - Country:US
Practice Address - Phone:360-861-8318
Practice Address - Fax:360-861-8539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000010695122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1386734416OtherNPI
1427022326OtherNPI