Provider Demographics
NPI:1124076500
Name:BIFANO, CARL ANGELO (DMD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:ANGELO
Last Name:BIFANO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FEDERAL ST STE SW200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1155
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:
Practice Address - Street 1:2 PLAZA DR STE 202
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080
Practice Address - Country:US
Practice Address - Phone:856-270-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD68331223P0106X
NJDI024579001223P0106X
PADS019214L1223S0112X
NJ22D102457901204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025303770001Medicaid
PADS019214LOtherLICENSE
NJDI02457900OtherSTATE LICENSE