Healthcare Provider Details

I. General information

NPI: 1215043344
Provider Name (Legal Business Name): TERYL DALE EDWARDS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

220 W RIDGEWAY SUITE 201
WATERLOO IA
50701
US

IV. Provider business mailing address

228 BERKSHIRE RD
WATERLOO IA
50701
US

V. Phone/Fax

Practice location:
  • Phone: 319-232-9023
  • Fax: 319-232-1610
Mailing address:
  • Phone: 319-232-4505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6453
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: