Basic Information
Provider Information | |||||||||
NPI: | 1124076500 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BIFANO | ||||||||
FirstName: | CARL | ||||||||
MiddleName: | ANGELO | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 FEDERAL ST STE SW200 | ||||||||
Address2: |   | ||||||||
City: | CAMDEN | ||||||||
State: | NJ | ||||||||
PostalCode: | 081031155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8563564924 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2 PLAZA DR STE 202 | ||||||||
Address2: |   | ||||||||
City: | SEWELL | ||||||||
State: | NJ | ||||||||
PostalCode: | 08080 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8562704100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2006 | ||||||||
LastUpdateDate: | 04/01/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0106X | 6833 | MD | N |   | Dental Providers | Dentist | Oral and Maxillofacial Pathology | 1223P0106X | DI02457900 | NJ | N |   | Dental Providers | Dentist | Oral and Maxillofacial Pathology | 1223S0112X | DS019214L | PA | N |   | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 204E00000X | 22D102457901 | NJ | Y |   | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 1025303770001 | 05 | PA |   | MEDICAID | DS019214L | 01 | PA | LICENSE | OTHER | DI02457900 | 01 | NJ | STATE LICENSE | OTHER |