Provider Demographics
NPI:1245318625
Name:BRIDGEFORD, CHARLES LEE (DDS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:BRIDGEFORD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 NORTH WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203
Mailing Address - Country:US
Mailing Address - Phone:701-746-0485
Mailing Address - Fax:701-746-3201
Practice Address - Street 1:117 NORTH WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203
Practice Address - Country:US
Practice Address - Phone:701-746-0485
Practice Address - Fax:701-746-3201
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1631122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND41252Medicaid
901631OtherDENTAL SERVICE CORP INSUR
672283OtherUNITED CONCORDIA MILITARY