Provider Demographics
NPI:1295794709
Name:ST. GEORGE, EDWARD NICHOLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:NICHOLAS
Last Name:ST. GEORGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:E
Other - Middle Name:N
Other - Last Name:ST. GEORGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:19640 LARCHMONT CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-6646
Mailing Address - Country:US
Mailing Address - Phone:714-536-8811
Mailing Address - Fax:714-536-8811
Practice Address - Street 1:10249 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-2362
Practice Address - Country:US
Practice Address - Phone:562-927-2602
Practice Address - Fax:562-928-9232
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA214041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice