Provider Demographics
NPI:1982702502
Name:PARKS, EDWIN THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:THOMAS
Last Name:PARKS
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 1:1121 W. MICHIGAN ST.
Mailing Address - Street 2:RM S110B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5186
Mailing Address - Country:US
Mailing Address - Phone:317-278-3306
Mailing Address - Fax:317-278-3018
Practice Address - Street 1:1121 W. MICHIGAN ST.
Practice Address - Street 2:RM S110B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5186
Practice Address - Country:US
Practice Address - Phone:317-278-3306
Practice Address - Fax:317-278-3018
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009393122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist