Provider Demographics
NPI:1912951302
Name:SECORD, EDWIN DEWITT III (DDS)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:DEWITT
Last Name:SECORD
Suffix:III
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 1:24825 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1757
Mailing Address - Country:US
Mailing Address - Phone:313-561-6160
Mailing Address - Fax:313-561-1061
Practice Address - Street 1:24825 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1757
Practice Address - Country:US
Practice Address - Phone:313-561-6160
Practice Address - Fax:313-561-1061
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI9376122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist