Provider Demographics
NPI:1528102183
Name:EDWARDS, R DOUGLAS JR (DMD)
Entity type:Individual
Prefix:DR
First Name:R
Middle Name:DOUGLAS
Last Name:EDWARDS
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:DOUGLAS
Other - Last Name:EDWARDS
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:3807 FREEDOM WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229
Mailing Address - Country:US
Mailing Address - Phone:502-969-3205
Mailing Address - Fax:520-969-8306
Practice Address - Street 1:3807 FREEDOM WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40229
Practice Address - Country:US
Practice Address - Phone:502-969-3205
Practice Address - Fax:520-969-8306
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4050122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60040508Medicaid