Provider Demographics
NPI:1255878104
Name:EDWARDS, DOUGLAS G (DMD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:G
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 1:204 37TH AVE N # 404
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-1416
Mailing Address - Country:US
Mailing Address - Phone:516-987-1934
Mailing Address - Fax:
Practice Address - Street 1:4714 N ARMENIA AVE STE 200
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2603
Practice Address - Country:US
Practice Address - Phone:813-885-6555
Practice Address - Fax:318-262-2527
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN232541223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery