=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366795718
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EFDG GENEVA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2012
-----------------------------------------------------
Last Update Date | 09/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64 ELIZABETH BLACKWELL ST SUITE B
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14456-3403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-789-8899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 64 ELIZABETH BLACKWELL ST SUITE B
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14456-3403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-789-8899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. EDMUND E EAVES
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 315-536-3341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------