Provider Demographics
NPI:1588072391
Name:EDGERLEY, PAUL DOUGLAS (DDS, MDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DOUGLAS
Last Name:EDGERLEY
Suffix:
Gender:M
Credentials:DDS, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14377 WOODLAKE DR STE 206
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-5735
Mailing Address - Country:US
Mailing Address - Phone:314-878-8880
Mailing Address - Fax:314-658-9940
Practice Address - Street 1:14377 WOODLAKE DR STE 206
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-5735
Practice Address - Country:US
Practice Address - Phone:314-878-8880
Practice Address - Fax:314-658-9940
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150143601223P0700X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist