Provider Demographics
NPI:1720372899
Name:BELLEFONTAINE DENTAL, MARK R. BEDFORD, DDS, LLC
Entity Type:Organization
Organization Name:BELLEFONTAINE DENTAL, MARK R. BEDFORD, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:S
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-206-4080
Mailing Address - Street 1:137 W CHILLICOTHE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-1472
Mailing Address - Country:US
Mailing Address - Phone:937-592-1776
Mailing Address - Fax:937-592-4566
Practice Address - Street 1:4 W MAIN ST
Practice Address - Street 2:SUITE 908
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-1300
Practice Address - Country:US
Practice Address - Phone:937-322-7832
Practice Address - Fax:937-322-7946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH15902122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty