Provider Demographics
NPI:1972606341
Name:EDWARDS, MARK ALLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
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 1:1161 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5332
Mailing Address - Country:US
Mailing Address - Phone:772-335-7766
Mailing Address - Fax:772-335-1951
Practice Address - Street 1:1161 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5332
Practice Address - Country:US
Practice Address - Phone:772-335-7766
Practice Address - Fax:772-335-1951
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10361122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist