Provider Demographics
NPI:1992172407
Name:EDWARDS, JEREMY RICHARD (DMD)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:RICHARD
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 CRANE FERRY RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3771
Mailing Address - Country:US
Mailing Address - Phone:678-855-3100
Mailing Address - Fax:
Practice Address - Street 1:3208 CRANE FERRY RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-3771
Practice Address - Country:US
Practice Address - Phone:678-855-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015006122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist