Provider Demographics
NPI:1386971810
Name:EDMISTON, DENISE (LAC)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:EDMISTON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 DICKENS DR
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2104
Mailing Address - Country:US
Mailing Address - Phone:512-586-1738
Mailing Address - Fax:
Practice Address - Street 1:413 W BETHEL RD
Practice Address - Street 2:SUITE 202
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-4473
Practice Address - Country:US
Practice Address - Phone:972-506-8113
Practice Address - Fax:214-432-0684
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01118171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist