Healthcare Provider Details

I. General information

NPI: 1740300029
Provider Name (Legal Business Name): BEDFORD COSMETIC & RESTORATIVE DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 ROUTE 101 UNIT 12A
BEDFORD NH
03110-5031
US

IV. Provider business mailing address

360 ROUTE 101 UNIT 12A
BEDFORD NH
03110-5031
US

V. Phone/Fax

Practice location:
  • Phone: 603-472-3667
  • Fax: 603-472-4758
Mailing address:
  • Phone: 603-472-3667
  • Fax: 603-472-4758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2215
License Number StateNH

VIII. Authorized Official

Name: JAY JOSEPH HEDSTROM
Title or Position: DDS OWNER
Credential: DDS
Phone: 603-472-3667