Provider Demographics
NPI:1528173853
Name:MCDONALD, EDWIN KENNETH III (DDS)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:KENNETH
Last Name:MCDONALD
Suffix:III
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 1:3195 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46409-1006
Mailing Address - Country:US
Mailing Address - Phone:219-887-0104
Mailing Address - Fax:219-887-0981
Practice Address - Street 1:3195 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-1006
Practice Address - Country:US
Practice Address - Phone:219-887-0104
Practice Address - Fax:219-887-0981
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8052122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN8052Medicaid