1275769929 NPI number — SOUTH BEDFORD ORAL & MAXILLOFACIAL SURGERY PLLC

Table of content: (NPI 1275769929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275769929 NPI number — SOUTH BEDFORD ORAL & MAXILLOFACIAL SURGERY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH BEDFORD ORAL & MAXILLOFACIAL SURGERY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275769929
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 SOUTH BEDFORD ROAD
Provider Second Line Business Mailing Address:
SUITE 330
Provider Business Mailing Address City Name:
MT. KISCO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10549-3466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-242-1142
Provider Business Mailing Address Fax Number:
914-242-1147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 SOUTH BEDFORD ROAD
Provider Second Line Business Practice Location Address:
SUITE 330
Provider Business Practice Location Address City Name:
MT. KISCO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10549-3466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-242-1142
Provider Business Practice Location Address Fax Number:
914-242-1147
Provider Enumeration Date:
06/09/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BAKER
Authorized Official First Name:
JASON
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
914-242-1142

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  051590 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223S0112X , with the licence number: 052234 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: 049711 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)