Provider Demographics
NPI:1063254415
Name:BEDFORD, KEVIN PATRICK (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:PATRICK
Last Name:BEDFORD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15817 GATESHEAD DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-5035
Mailing Address - Country:US
Mailing Address - Phone:570-390-0933
Mailing Address - Fax:
Practice Address - Street 1:330 PARK PL
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3555
Practice Address - Country:US
Practice Address - Phone:574-259-9956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014453A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist