Provider Demographics
NPI:1497727754
Name:EDMONDSON, C.W. URIAH (DDS)
Entity type:Individual
Prefix:DR
First Name:C.W.
Middle Name:URIAH
Last Name:EDMONDSON
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 1:360 SIMONTON CREST DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3509
Mailing Address - Country:US
Mailing Address - Phone:301-742-4079
Mailing Address - Fax:
Practice Address - Street 1:73666 JOSHUA DR
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-2572
Practice Address - Country:US
Practice Address - Phone:301-742-4079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD138211223G0001X
WV42371223G0001X
CA1113041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810021389Medicaid
MD039320700Medicaid