Provider Demographics
NPI:1619170412
Name:BEDFORD, NICHOLE ELIZABETH (RDH)
Entity Type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:ELIZABETH
Last Name:BEDFORD
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12987 RIDGE RD W
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:NY
Mailing Address - Zip Code:14411-9152
Mailing Address - Country:US
Mailing Address - Phone:585-746-4677
Mailing Address - Fax:585-637-4990
Practice Address - Street 1:300 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1118
Practice Address - Country:US
Practice Address - Phone:585-637-3905
Practice Address - Fax:585-637-4990
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024736124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355308Medicaid