Healthcare Provider Details

I. General information

NPI: 1699884965
Provider Name (Legal Business Name): EDWARDS & WILSON PERIODONTICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4830 QUAIL CREST PLACE
LAWRENCE KS
66049-3838
US

IV. Provider business mailing address

4830 QUAIL CREST PLACE
LAWRENCE KS
66049-3838
US

V. Phone/Fax

Practice location:
  • Phone: 785-843-4076
  • Fax: 785-843-6127
Mailing address:
  • Phone: 785-843-4076
  • Fax: 785-843-6127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6357
License Number StateKS

VIII. Authorized Official

Name: MRS. ASHLI E GILL
Title or Position: BILLING MANAGER
Credential:
Phone: 785-843-4076