Provider Demographics
NPI:1770503427
Name:EDWARDS, THOMAS WALTER JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:WALTER
Last Name:EDWARDS
Suffix:JR
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 1:10921 WILSHIRE BLVD STE 1010
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4003
Mailing Address - Country:US
Mailing Address - Phone:310-208-8661
Mailing Address - Fax:310-476-7215
Practice Address - Street 1:10921 WILSHIRE BLVD STE 1010
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4003
Practice Address - Country:US
Practice Address - Phone:310-208-8661
Practice Address - Fax:310-476-7215
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD205171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD20517OtherDENTIST