Provider Demographics
NPI:1265643977
Name:EDGE CENTER FOR FAMILY DENTISTRY
Entity type:Organization
Organization Name:EDGE CENTER FOR FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:CARTER
Authorized Official - Last Name:EDGE
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:770-974-5293
Mailing Address - Street 1:3420 ACWORTH DUE WEST RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144
Mailing Address - Country:US
Mailing Address - Phone:770-974-5293
Mailing Address - Fax:770-974-7285
Practice Address - Street 1:3420 ACWORTH DUE WEST RD
Practice Address - Street 2:SUITE A
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144
Practice Address - Country:US
Practice Address - Phone:770-974-5293
Practice Address - Fax:770-974-7285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty