Provider Demographics
NPI:1538578919
Name:COURTNEY P EDWARDS
Entity type:Organization
Organization Name:COURTNEY P EDWARDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-817-8728
Mailing Address - Street 1:2303 W MOREHEAD ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5186
Mailing Address - Country:US
Mailing Address - Phone:704-817-8727
Mailing Address - Fax:704-817-7538
Practice Address - Street 1:2303 W MOREHEAD ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-5186
Practice Address - Country:US
Practice Address - Phone:704-817-8728
Practice Address - Fax:704-817-7538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8943122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5914560Medicaid