Provider Demographics
NPI:1356334072
Name:EDWARDS, PAUL C (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:C
Last Name:EDWARDS
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 1:1121 W MICHIGAN STREET
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5186
Mailing Address - Country:US
Mailing Address - Phone:317-274-5628
Mailing Address - Fax:317-274-2603
Practice Address - Street 1:1121 W MICHIGAN STREET
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5186
Practice Address - Country:US
Practice Address - Phone:317-274-5628
Practice Address - Fax:317-274-2603
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1061223P0106X
MI2901019526122300000X
IN12012036A1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM86970005Medicare PIN