=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023279866
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN C EDGAR D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2008
-----------------------------------------------------
Last Update Date | 10/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 LANDOVER PKWY SUITE A
-----------------------------------------------------
City | HAWTHORN WOODS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60047-7513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-550-5000
-----------------------------------------------------
Fax | 847-550-5081
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 60 LANDOVER PKWY SUITE A
-----------------------------------------------------
City | HAWTHORN WOODS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60047-7513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-550-5000
-----------------------------------------------------
Fax | 847-550-5081
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 19A16412
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------