Healthcare Provider Details

I. General information

NPI: 1275769929
Provider Name (Legal Business Name): SOUTH BEDFORD ORAL & MAXILLOFACIAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 SOUTH BEDFORD ROAD SUITE 330
MT. KISCO NY
10549-3466
US

IV. Provider business mailing address

105 SOUTH BEDFORD ROAD SUITE 330
MT. KISCO NY
10549-3466
US

V. Phone/Fax

Practice location:
  • Phone: 914-242-1142
  • Fax: 914-242-1147
Mailing address:
  • Phone: 914-242-1142
  • Fax: 914-242-1147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number052234
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number049711
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number051590
License Number StateNY

VIII. Authorized Official

Name: DR. JASON BAKER
Title or Position: OWNER
Credential: DMD
Phone: 914-242-1142