Healthcare Provider Details

I. General information

NPI: 1780691352
Provider Name (Legal Business Name): MARK R BEDFORD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 FRONT ST
BEREA OH
44017-1760
US

IV. Provider business mailing address

359 FRONT ST
BEREA OH
44017-1760
US

V. Phone/Fax

Practice location:
  • Phone: 440-234-2813
  • Fax: 440-234-7812
Mailing address:
  • Phone: 440-234-2813
  • Fax: 440-234-7812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15902
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: