Healthcare Provider Details

I. General information

NPI: 1013073618
Provider Name (Legal Business Name): MICHAEL L EDGAR DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 E MAIN ST
PARK HILLS MO
63601-2717
US

IV. Provider business mailing address

919 E MAIN ST
PARK HILLS MO
63601-2717
US

V. Phone/Fax

Practice location:
  • Phone: 573-431-5566
  • Fax: 573-431-3345
Mailing address:
  • Phone: 573-431-5566
  • Fax: 573-431-3345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number014114
License Number StateMO

VIII. Authorized Official

Name: DR. MICHAEL L EDGAR
Title or Position: PRESIDENT
Credential: DDS
Phone: 573-431-5566