Provider Demographics
NPI:1740300029
Name:BEDFORD COSMETIC & RESTORATIVE DENTISTRY LLC
Entity type:Organization
Organization Name:BEDFORD COSMETIC & RESTORATIVE DENTISTRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DDS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:HEDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:603-472-3667
Mailing Address - Street 1:360 ROUTE 101
Mailing Address - Street 2:UNIT 12A
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-5031
Mailing Address - Country:US
Mailing Address - Phone:603-472-3667
Mailing Address - Fax:603-472-4758
Practice Address - Street 1:360 ROUTE 101
Practice Address - Street 2:UNIT 12A
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-5031
Practice Address - Country:US
Practice Address - Phone:603-472-3667
Practice Address - Fax:603-472-4758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH22151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty