Provider Demographics
NPI:1871713743
Name:EDWARDS, CLARON S (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:CLARON
Middle Name:S
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 W PETERSON AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5713
Mailing Address - Country:US
Mailing Address - Phone:773-777-0600
Mailing Address - Fax:773-777-9340
Practice Address - Street 1:4801 W PETERSON AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5713
Practice Address - Country:US
Practice Address - Phone:773-777-0600
Practice Address - Fax:773-777-9340
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics