Provider Demographics
NPI:1083663702
Name:BEDELL, SHADOWS OYE (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHADOWS
Middle Name:OYE
Last Name:BEDELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19600 VAN DYKE STREET
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-3328
Mailing Address - Country:US
Mailing Address - Phone:313-892-9100
Mailing Address - Fax:313-892-0204
Practice Address - Street 1:19600 VAN DYKE STREET
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-3328
Practice Address - Country:US
Practice Address - Phone:313-892-9100
Practice Address - Fax:313-892-0204
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010123601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1240515450372Medicaid
MI1242908490512Medicaid