Provider Demographics
NPI:1770784746
Name:EDWARDS, DANIEL SHANE (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:SHANE
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 1:42 HARLAN RD
Mailing Address - Street 2:
Mailing Address - City:POTTSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:75076-4101
Mailing Address - Country:US
Mailing Address - Phone:214-632-4600
Mailing Address - Fax:
Practice Address - Street 1:103 N BRENTWOOD STE 400
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-7147
Practice Address - Country:US
Practice Address - Phone:366-394-8679
Practice Address - Fax:936-639-4868
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX181171223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752851171OtherTAX ID