Provider Demographics
NPI:1093825135
Name:BEDFORD DENTAL CARE, PC
Entity Type:Organization
Organization Name:BEDFORD DENTAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:JILL
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:812-279-6455
Mailing Address - Street 1:2906 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-5288
Mailing Address - Country:US
Mailing Address - Phone:812-279-6455
Mailing Address - Fax:812-279-0130
Practice Address - Street 1:2906 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-5288
Practice Address - Country:US
Practice Address - Phone:812-279-6455
Practice Address - Fax:812-279-0130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120101401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty