1790126621 NPI number — KENNETH M. BERRIN, DDS, INC.

Table of content: (NPI 1790126621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790126621 NPI number — KENNETH M. BERRIN, DDS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH M. BERRIN, DDS, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1790126621
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13132B POWAY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POWAY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92064-4612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-486-2224
Provider Business Mailing Address Fax Number:
858-486-2317

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13132B POWAY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POWAY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92064-4612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-486-2224
Provider Business Practice Location Address Fax Number:
858-486-2317
Provider Enumeration Date:
07/08/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BERRIN
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
MARK
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
858-486-2224

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  29775 , 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: 1255338190 . This is a "NPI NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 29775 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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