1295794709 NPI number — DR. EDWARD NICHOLAS ST. GEORGE DDS

Table of content: DR. EDWARD NICHOLAS ST. GEORGE DDS (NPI 1295794709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295794709 NPI number — DR. EDWARD NICHOLAS ST. GEORGE DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ST. GEORGE
Provider First Name:
EDWARD
Provider Middle Name:
NICHOLAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ST. GEORGE
Provider Other First Name:
E
Provider Other Middle Name:
N
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1295794709
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19640 LARCHMONT CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92648-6646
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-536-8811
Provider Business Mailing Address Fax Number:
714-536-8811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10249 PARAMOUNT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOWNEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90241-2362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-927-2602
Provider Business Practice Location Address Fax Number:
562-928-9232
Provider Enumeration Date:
03/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  21404 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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