MEDICARE: DR. RICHARD LEON EDWARDS IV D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	57604	CA
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1811180961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD LEON EDWARDS IV D.D.S

Provider Business Mailing Address
First Line	:	2708 WILSHIRE BLVD # 141
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-4706
Country	:	US
Telephone Number	:	310-895-4229
Fax Number	:

Provider Business Practice Location Address
First Line	:	2730 WILSHIRE BLVD.,#410
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-4706
Country	:	US
Telephone Number	:	310-453-8606
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	01/12/2016

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