Provider Demographics
NPI:1275769929
Name:SOUTH BEDFORD ORAL & MAXILLOFACIAL SURGERY PLLC
Entity Type:Organization
Organization Name:SOUTH BEDFORD ORAL & MAXILLOFACIAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:914-242-1142
Mailing Address - Street 1:105 SOUTH BEDFORD ROAD
Mailing Address - Street 2:SUITE 330
Mailing Address - City:MT. KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-3466
Mailing Address - Country:US
Mailing Address - Phone:914-242-1142
Mailing Address - Fax:914-242-1147
Practice Address - Street 1:105 SOUTH BEDFORD ROAD
Practice Address - Street 2:SUITE 330
Practice Address - City:MT. KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549-3466
Practice Address - Country:US
Practice Address - Phone:914-242-1142
Practice Address - Fax:914-242-1147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-09
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0515901223S0112X
NY0522341223S0112X
NY0497111223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty