Healthcare Provider Details

I. General information

NPI: 1124076500
Provider Name (Legal Business Name): CARL ANGELO BIFANO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 04/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PLAZA DR STE 202
SEWELL NJ
08080
US

IV. Provider business mailing address

1 FEDERAL ST STE SW200
CAMDEN NJ
08103-1155
US

V. Phone/Fax

Practice location:
  • Phone: 856-270-4100
  • Fax:
Mailing address:
  • Phone: 856-356-4924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number6833
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDI02457900
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS019214L
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number22D102457901
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: