Provider Demographics
NPI:1427148865
Name:EDWARDS, JOHN GREGGORY (DDS)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:GREGGORY
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1785 SAN CARLOS AVE
Mailing Address - Street 2:STE 6
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-2026
Mailing Address - Country:US
Mailing Address - Phone:650-591-9977
Mailing Address - Fax:650-637-2005
Practice Address - Street 1:1785 SAN CARLOS AVE
Practice Address - Street 2:STE 6
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2026
Practice Address - Country:US
Practice Address - Phone:650-591-9977
Practice Address - Fax:650-637-2005
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2477201OtherDENTI CAL
CA400149OtherCITY OF SAN CARLOS
508480Medicare UPIN