1821290230 NPI number — JOHN GREGGORY EDWARDS

Table of content: (NPI 1821290230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821290230 NPI number — JOHN GREGGORY EDWARDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN GREGGORY EDWARDS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821290230
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1785 SAN CARLOS AVE
Provider Second Line Business Mailing Address:
STE #6
Provider Business Mailing Address City Name:
SAN CARLOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94070-2026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-591-9977
Provider Business Mailing Address Fax Number:
650-637-2005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1785 SAN CARLOS AVE
Provider Second Line Business Practice Location Address:
STE #6
Provider Business Practice Location Address City Name:
SAN CARLOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94070-2026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-591-9977
Provider Business Practice Location Address Fax Number:
650-637-2005
Provider Enumeration Date:
06/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
GREGGORY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
650-591-9977

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  24772 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: B2477201 . This is a "DENTICAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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