Provider Demographics
NPI:1699906255
Name:EDWARDS, JUSTIN S (DMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:S
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 ROCK WREN DRIVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23140
Mailing Address - Country:US
Mailing Address - Phone:509-434-9364
Mailing Address - Fax:
Practice Address - Street 1:2113 HARTFORD RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2575
Practice Address - Country:US
Practice Address - Phone:757-838-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04420001071223G0001X
VA04014132601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice