Provider Demographics
NPI:1932102233
Name:EDWARDS, MARK VINCENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:VINCENT
Last Name:EDWARDS
Suffix:
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 1:2600 SOUTH LOOP W
Mailing Address - Street 2:STE 410
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2642
Mailing Address - Country:US
Mailing Address - Phone:713-669-9864
Mailing Address - Fax:713-669-9849
Practice Address - Street 1:2600 SOUTH LOOP W
Practice Address - Street 2:STE 410
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2642
Practice Address - Country:US
Practice Address - Phone:713-669-9864
Practice Address - Fax:713-669-9849
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2009-11-10
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2009-10-16
Provider Licenses
StateLicense IDTaxonomies
TX152361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice