Healthcare Provider Details

I. General information

NPI: 1467423103
Provider Name (Legal Business Name): THOMAS PAUL EDMONSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 11/07/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51ST MEDICAL GROUP UNIT 2060
APO AP
96278-2060
US

IV. Provider business mailing address

673MDG 5955 ZEAMER AVENUE
JBER AK
99506
US

V. Phone/Fax

Practice location:
  • Phone: 315-784-0196
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3036-98
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: