Provider Demographics
NPI:1821290230
Name:JOHN GREGGORY EDWARDS
Entity Type:Organization
Organization Name:JOHN GREGGORY EDWARDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GREGGORY
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-591-9977
Mailing Address - Street 1:1785 SAN CARLOS AVE
Mailing Address - Street 2:STE #6
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-2026
Mailing Address - Country:US
Mailing Address - Phone:650-591-9977
Mailing Address - Fax:650-637-2005
Practice Address - Street 1:1785 SAN CARLOS AVE
Practice Address - Street 2:STE #6
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2026
Practice Address - Country:US
Practice Address - Phone:650-591-9977
Practice Address - Fax:650-637-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
24772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2477201OtherDENTICAL
CAB2477201OtherDENTICAL