Healthcare Provider Details

I. General information

NPI: 1295794709
Provider Name (Legal Business Name): EDWARD NICHOLAS ST. GEORGE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: E N ST. GEORGE DDS

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10249 PARAMOUNT BLVD
DOWNEY CA
90241-2362
US

IV. Provider business mailing address

19640 LARCHMONT CIR
HUNTINGTON BEACH CA
92648-6646
US

V. Phone/Fax

Practice location:
  • Phone: 562-927-2602
  • Fax: 562-928-9232
Mailing address:
  • Phone: 714-536-8811
  • Fax: 714-536-8811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21404
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: