Healthcare Provider Details

I. General information

NPI: 1881699650
Provider Name (Legal Business Name): EDWIN LYNN MCLARTY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 MICCOSUKEE RD
TALLAHASSEE FL
32308-5321
US

IV. Provider business mailing address

1919 MICCOSUKEE RD
TALLAHASSEE FL
32308-5321
US

V. Phone/Fax

Practice location:
  • Phone: 850-878-7200
  • Fax: 850-878-0349
Mailing address:
  • Phone: 850-878-7200
  • Fax: 850-878-0349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN5256
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: