Healthcare Provider Details

I. General information

NPI: 1245396894
Provider Name (Legal Business Name): KEN E EDWARDS III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 SATELLITE BLVD
DULUTH GA
30096
US

IV. Provider business mailing address

1650 OAKBROOK DR SUITE 440
NORCROSS GA
30093
US

V. Phone/Fax

Practice location:
  • Phone: 770-476-9000
  • Fax:
Mailing address:
  • Phone: 770-446-8000
  • Fax: 770-446-8000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberGA8493
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: