Provider Demographics
NPI:1649356098
Name:EDMOND DE ST GEORGES DDS INC
Entity type:Organization
Organization Name:EDMOND DE ST GEORGES DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:DE ST GEORGES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-263-1255
Mailing Address - Street 1:452 E CALAVERAS BLVD
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-5412
Mailing Address - Country:US
Mailing Address - Phone:408-263-1255
Mailing Address - Fax:408-263-5167
Practice Address - Street 1:452 E CALAVERAS BLVD
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-5412
Practice Address - Country:US
Practice Address - Phone:408-263-1255
Practice Address - Fax:408-263-5167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-28
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19493122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty