Healthcare Provider Details

I. General information

NPI: 1417330705
Provider Name (Legal Business Name): JESSE IVEY EDWARDS III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2015
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WAHOO AVE
GROTON CT
06349-2324
US

IV. Provider business mailing address

1647 ADMIRAL TAUSSIG BLVD
NORFOLK VA
23511-2803
US

V. Phone/Fax

Practice location:
  • Phone: 860-694-3047
  • Fax:
Mailing address:
  • Phone: 757-953-8604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901021535
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401418304
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number13704
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: