Provider Demographics
NPI:1346919511
Name:BRADFORD DENTAL CENTER
Entity Type:Organization
Organization Name:BRADFORD DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENNARDI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:814-245-2119
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:EMPORIUM
Mailing Address - State:PA
Mailing Address - Zip Code:15834-0270
Mailing Address - Country:US
Mailing Address - Phone:814-486-1115
Mailing Address - Fax:814-486-0404
Practice Address - Street 1:600 CHESTNUT STREET EXT STE B
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-5438
Practice Address - Country:US
Practice Address - Phone:814-366-5955
Practice Address - Fax:814-366-5990
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEYSTONE RURAL HEALTH CONSORTIA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty