Provider Demographics
NPI:1023060365
Name:KING, EDWIN D (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:D
Last Name:KING
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 1:845 W 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702
Mailing Address - Country:US
Mailing Address - Phone:319-235-9385
Mailing Address - Fax:319-236-7991
Practice Address - Street 1:845 W 4TH STREET
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702
Practice Address - Country:US
Practice Address - Phone:319-235-9385
Practice Address - Fax:319-236-7991
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA66471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA183608OtherDENTAL INSURANCES
IA18360OtherBLUE CROSS BLUE SHIELD
T01055Medicare UPIN