Provider Demographics
NPI:1245572551
Name:BIDWELL, MARK LAMONT (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LAMONT
Last Name:BIDWELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 SKIPPACK PIKE
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1246
Mailing Address - Country:US
Mailing Address - Phone:610-279-4277
Mailing Address - Fax:
Practice Address - Street 1:1213 SKIPPACK PIKE
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-1246
Practice Address - Country:US
Practice Address - Phone:610-279-4277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026761L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist