Provider Demographics
NPI:1427247758
Name:SHADOWS O.BEDELL DDS.P.C.
Entity type:Organization
Organization Name:SHADOWS O.BEDELL DDS.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHADOWS
Authorized Official - Middle Name:O
Authorized Official - Last Name:BEDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDSPC
Authorized Official - Phone:313-892-9148
Mailing Address - Street 1:19600 VAN DYKE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-3325
Mailing Address - Country:US
Mailing Address - Phone:313-892-9148
Mailing Address - Fax:313-892-0204
Practice Address - Street 1:19600 VAN DYKE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-3325
Practice Address - Country:US
Practice Address - Phone:313-892-9148
Practice Address - Fax:313-892-0204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI123601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1720148018Medicaid
MI1801967757Medicaid
MI1083663702Medicaid