Healthcare Provider Details

I. General information

NPI: 1346104957
Provider Name (Legal Business Name): EDELWOOD PRACTICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 OLD FARM DR
FREDERICK MD
21702-9494
US

IV. Provider business mailing address

2100 OLD FARM DR
FREDERICK MD
21702-9494
US

V. Phone/Fax

Practice location:
  • Phone: 626-242-6456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JIAN LEE
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 626-242-6456