Provider Demographics
NPI:1255401956
Name:REIDY, EDWARD THOMAS III (DDS)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:THOMAS
Last Name:REIDY
Suffix:III
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 1:9280 MAST BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071
Mailing Address - Country:US
Mailing Address - Phone:619-449-8530
Mailing Address - Fax:619-449-8531
Practice Address - Street 1:9280 MAST BLVD
Practice Address - Street 2:
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071
Practice Address - Country:US
Practice Address - Phone:619-449-8530
Practice Address - Fax:619-449-8531
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA273571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice