1720372899 NPI number — BELLEFONTAINE DENTAL, MARK R. BEDFORD, DDS, LLC

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 1720372899 NPI number — BELLEFONTAINE DENTAL, MARK R. BEDFORD, DDS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELLEFONTAINE DENTAL, MARK R. BEDFORD, DDS, LLC
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:
1720372899
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
137 W CHILLICOTHE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLEFONTAINE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43311-1472
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-592-1776
Provider Business Mailing Address Fax Number:
937-592-4566

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 908
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45502-1300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-322-7832
Provider Business Practice Location Address Fax Number:
937-322-7946
Provider Enumeration Date:
06/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
937-206-4080

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  15902 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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