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General NPI Number Information
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NPI Number | 1003920174
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Entity Type | Individual
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Provider Name | MICHAEL EDLIN JR. D.M.D
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Gender | Male
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Dates
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Enumeration Date | 08/18/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 8000 BONHOMME AVE SUITE 306
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City | SAINT LOUIS
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State | MO
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Zip | 63105-3515
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Country | US
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Telephone | 314-863-2222
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Fax | 314-863-5225
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Provider Business Mailing Address
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Address Line | 8000 BONHOMME AVE. SUITE 306
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City | ST. LOUIS
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State | MO
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Zip | 63105
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Country | US
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Telephone | 314-863-2222
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Fax | 314-863-5225
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 14966
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License Number State | MO
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