Provider Demographics
NPI:1639410178
Name:EDWARDS, BRUCE D (DDS)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
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 1:2115 M-119
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770
Mailing Address - Country:US
Mailing Address - Phone:231-347-2518
Mailing Address - Fax:231-347-8530
Practice Address - Street 1:2115 M-119
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770
Practice Address - Country:US
Practice Address - Phone:231-347-2518
Practice Address - Fax:231-347-8530
Is Sole Proprietor?:No
Enumeration Date:2013-03-08
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010208691223P0300X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No1223G0001XDental ProvidersDentistGeneral Practice