Healthcare Provider Details

I. General information

NPI: 1932102233
Provider Name (Legal Business Name): MARK VINCENT EDWARDS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 10/16/2009

III. Provider practice location address

2600 SOUTH LOOP W STE 410
HOUSTON TX
77054-2642
US

IV. Provider business mailing address

2600 SOUTH LOOP W STE 410
HOUSTON TX
77054-2642
US

V. Phone/Fax

Practice location:
  • Phone: 713-669-9864
  • Fax: 713-669-9849
Mailing address:
  • Phone: 713-669-9864
  • Fax: 713-669-9849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15236
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: