Healthcare Provider Details

I. General information

NPI: 1255420600
Provider Name (Legal Business Name): MICHAEL DOUGLAS EDWARDS DDS,MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8801 N MERIDIAN ST SUITE 103
INDIANAPOLIS IN
46260-2396
US

IV. Provider business mailing address

8801 N MERIDIAN ST SUITE 103
INDIANAPOLIS IN
46260-2396
US

V. Phone/Fax

Practice location:
  • Phone: 317-574-0600
  • Fax: 317-574-0606
Mailing address:
  • Phone: 317-574-0600
  • Fax: 317-574-0606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number12010349A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: