Healthcare Provider Details

I. General information

NPI: 1033190640
Provider Name (Legal Business Name): BEDFORD DENTAL PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 ECHO VALE DR
BEDFORD PA
15522
US

IV. Provider business mailing address

902 ECHO VALE DR
BEDFORD PA
15522
US

V. Phone/Fax

Practice location:
  • Phone: 814-623-2217
  • Fax: 814-623-6271
Mailing address:
  • Phone: 814-623-2217
  • Fax: 814-623-6271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS020764L
License Number StatePA

VIII. Authorized Official

Name: DR. WILLIAM MICHAEL STIFFLER
Title or Position: PRESIDENT CORP
Credential: DDS
Phone: 814-623-2217