=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396979530
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COSMETIC & NATURAL DENTISTRY P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2009
-----------------------------------------------------
Last Update Date | 05/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1137 COMMERCIAL DR SE
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-4658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-896-9399
-----------------------------------------------------
Fax | 505-896-1686
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1137 COMMERCIAL DR SE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-4658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-896-9399
-----------------------------------------------------
Fax | 505-896-1686
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ANTHONY HERBERT EDWARDS
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 505-896-9399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DD2550
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DD2548
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------