Provider Demographics
NPI:1821097122
Name:EDWARDS, KEVIN RAY (DDS LLC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RAY
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DDS LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 SW 11TH AVE
Mailing Address - Street 2:SUITE 910
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2125
Mailing Address - Country:US
Mailing Address - Phone:503-222-5580
Mailing Address - Fax:503-224-4079
Practice Address - Street 1:833 SW 11TH AVE
Practice Address - Street 2:SUITE 910
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2125
Practice Address - Country:US
Practice Address - Phone:503-222-5580
Practice Address - Fax:503-224-4079
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR078771223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1326008OtherUNITED CONCORDIA