Healthcare Provider Details

I. General information

NPI: 1639456395
Provider Name (Legal Business Name): EDWARD CLARK STURDIVANT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 11/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 LAWRENCE STREET
PORT TOWNSEND WA
98368-2224
US

IV. Provider business mailing address

1119 LAWRENCE STREET
PORT TOWNSEND WA
98368-2224
US

V. Phone/Fax

Practice location:
  • Phone: 360-385-5121
  • Fax:
Mailing address:
  • Phone: 360-385-5121
  • Fax: 360-379-9534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00004262
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: