Healthcare Provider Details

I. General information

NPI: 1346222874
Provider Name (Legal Business Name): ROBERT LADD EDMONSTONE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 MAIN ST
OLD SAYBROOK CT
06475-2357
US

IV. Provider business mailing address

251 MAIN ST
OLD SAYBROOK CT
06475-2357
US

V. Phone/Fax

Practice location:
  • Phone: 860-388-0142
  • Fax: 860-388-9855
Mailing address:
  • Phone: 860-388-9855
  • Fax: 860-388-9855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5577
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: