Healthcare Provider Details

I. General information

NPI: 1013377829
Provider Name (Legal Business Name): JONATHON EDWARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1327 S NIELSON ST
GILBERT AZ
85296-4265
US

IV. Provider business mailing address

1327 S NIELSON ST
GILBERT AZ
85296-4265
US

V. Phone/Fax

Practice location:
  • Phone: 480-868-1864
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD009375
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: