Provider Demographics
NPI:1205996055
Name:EDMONDS, GREGORY PAUL (DDS)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:PAUL
Last Name:EDMONDS
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 1:15215 S 48TH ST
Mailing Address - Street 2:#158
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-9139
Mailing Address - Country:US
Mailing Address - Phone:480-598-3006
Mailing Address - Fax:480-598-1184
Practice Address - Street 1:15215 S 48TH ST
Practice Address - Street 2:#158
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-9139
Practice Address - Country:US
Practice Address - Phone:480-598-3006
Practice Address - Fax:480-598-1184
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD4010122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DDS4010Medicare ID - Type Unspecified
U52264Medicare UPIN