1083021042 NPI number — DR. JUAN BERNAL GENERAL DENTIST/IMPL

Table of content: DR. JUAN BERNAL GENERAL DENTIST/IMPL (NPI 1083021042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083021042 NPI number — DR. JUAN BERNAL GENERAL DENTIST/IMPL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERNAL
Provider First Name:
JUAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
GENERAL DENTIST/IMPL
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CASTANEDO
Provider Other First Name:
CARLOS
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
GENERAL DENTIST
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1083021042
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3RD STREET AND A
Provider Second Line Business Mailing Address:
SUITE #8
Provider Business Mailing Address City Name:
LOS ALGODONES
Provider Business Mailing Address State Name:
MEXICALI
Provider Business Mailing Address Postal Code:
21970
Provider Business Mailing Address Country Code:
MX
Provider Business Mailing Address Telephone Number:
928-328-8237
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3RD STREET AND AVE. A
Provider Second Line Business Practice Location Address:
SUITE #8
Provider Business Practice Location Address City Name:
SAN LUIS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85349-6173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-328-8237
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/22/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3862950 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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