Provider Demographics
NPI:1912087131
Name:ROYAL, EDWARD MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MARK
Last Name:ROYAL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42051 MOUND RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-3143
Mailing Address - Country:US
Mailing Address - Phone:586-323-7700
Mailing Address - Fax:586-323-7707
Practice Address - Street 1:42051 MOUND RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-3143
Practice Address - Country:US
Practice Address - Phone:586-323-7700
Practice Address - Fax:586-323-7707
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010120921223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4062692Medicaid
MI4062692Medicaid
MI5636876Medicare ID - Type UnspecifiedPROVIDER #