1710182480 NPI number — G.L. BERRY D.D.S., A DENTAL CORPORATION

Table of content: (NPI 1710182480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710182480 NPI number — G.L. BERRY D.D.S., A DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
G.L. BERRY D.D.S., A DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NEIGHBORHOOD FAMILY DENTAL PRACTICE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710182480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4655 CASS ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92109-2809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-362-3540
Provider Business Mailing Address Fax Number:
858-362-3544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4655 CASS ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92109-2809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-362-3540
Provider Business Practice Location Address Fax Number:
858-362-3544
Provider Enumeration Date:
06/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BERRY
Authorized Official First Name:
GLADYS
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
858-362-3540

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  39969 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G98442-01 . This is a "HEALTHY FAMILIES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1396846036 . This is a "TYPE 1 NPI NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: G93297-01 . This is a "DENTI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com