Healthcare Provider Details

I. General information

NPI: 1801890520
Provider Name (Legal Business Name): BERNARD JAY ASDELL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date: 03/15/2006
Reactivation Date: 03/23/2006

III. Provider practice location address

707 N MICHIGAN ST STE 300
SOUTH BEND IN
46601-1070
US

IV. Provider business mailing address

707 N MICHIGAN ST SUITE 300
SOUTH BEND IN
46601
US

V. Phone/Fax

Practice location:
  • Phone: 574-289-0080
  • Fax: 574-287-6320
Mailing address:
  • Phone: 574-289-0080
  • Fax: 574-287-6320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12008287
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: