1427247758 NPI number — SHADOWS O.BEDELL DDS.P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427247758 NPI number — SHADOWS O.BEDELL DDS.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHADOWS O.BEDELL DDS.P.C.
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:
1427247758
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19600 VAN DYKE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48234-3325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-892-9148
Provider Business Mailing Address Fax Number:
313-892-0204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19600 VAN DYKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48234-3325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-892-9148
Provider Business Practice Location Address Fax Number:
313-892-0204
Provider Enumeration Date:
10/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BEDELL
Authorized Official First Name:
SHADOWS
Authorized Official Middle Name:
O
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
313-892-9148

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  12360 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1720148018 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1801967757 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1083663702 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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