Healthcare Provider Details

I. General information

NPI: 1386872075
Provider Name (Legal Business Name): GRACE M. EDWARDS DMD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16115 ST. VINCENT WAY SUITE 110
LITTLE ROCK AR
72223-3001
US

IV. Provider business mailing address

16115 ST. VINCENT WAY SUITE 110
LITTLE ROCK AR
72223-3001
US

V. Phone/Fax

Practice location:
  • Phone: 501-817-3157
  • Fax: 501-817-3160
Mailing address:
  • Phone: 501-817-3157
  • Fax: 501-817-3160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3579
License Number StateAR

VIII. Authorized Official

Name: MARY GRACE MAPILI EDWARDS
Title or Position: OWNER/DENTIST/PRESIDENT
Credential: DMD
Phone: 501-817-3157