Provider Demographics
NPI:1316917495
Name:EDGEWOOD FAMILY DENTISTRY
Entity type:Organization
Organization Name:EDGEWOOD FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARRINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-281-0373
Mailing Address - Street 1:PO BOX 2560
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-2560
Mailing Address - Country:US
Mailing Address - Phone:505-281-0373
Mailing Address - Fax:505-281-0373
Practice Address - Street 1:1917 OLD HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-0000
Practice Address - Country:US
Practice Address - Phone:505-281-0373
Practice Address - Fax:505-281-0373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM15801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM1580OtherSTEVE'S NM LISC #
NMNM1625OtherSUE'S NM LISC #