Provider Demographics
NPI:1205101201
Name:EDWARDS, PATRICK STEVENS (EFDA, RDA)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:STEVENS
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:EFDA, RDA
Other - Prefix:MR
Other - First Name:PATRICK
Other - Middle Name:STEVENS
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EFDA, RDA
Mailing Address - Street 1:8728 N HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-3426
Mailing Address - Country:US
Mailing Address - Phone:503-309-2651
Mailing Address - Fax:
Practice Address - Street 1:8728 N HAVEN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-3426
Practice Address - Country:US
Practice Address - Phone:503-309-2651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA30373126800000X
WAD1 60053125126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant