Provider Demographics
NPI:1992976070
Name:ENGEL, EDWARD L JR (DMD, MS)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
Last Name:ENGEL
Suffix:JR
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:843 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-5871
Mailing Address - Country:US
Mailing Address - Phone:662-378-8645
Mailing Address - Fax:662-332-9434
Practice Address - Street 1:843 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-5871
Practice Address - Country:US
Practice Address - Phone:662-378-8645
Practice Address - Fax:662-332-9434
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS171276122300000X
MSOR6771223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00005858Medicaid