Provider Demographics
NPI:1801890520
Name:ASDELL, BERNARD JAY (DDS)
Entity type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:JAY
Last Name:ASDELL
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 1:707 N MICHIGAN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601
Mailing Address - Country:US
Mailing Address - Phone:574-289-0080
Mailing Address - Fax:574-287-6320
Practice Address - Street 1:707 N MICHIGAN ST
Practice Address - Street 2:STE 300
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1070
Practice Address - Country:US
Practice Address - Phone:574-289-0080
Practice Address - Fax:574-287-6320
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2012-04-18
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
IN120082871223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100090950Medicaid
IN100090950Medicaid
IN210990Medicare PIN