Provider Demographics
NPI:1033396353
Name:BERRY, LILLIAN RUTH (DMD)
Entity Type:Individual
Prefix:DR
First Name:LILLIAN
Middle Name:RUTH
Last Name:BERRY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:168 14TH ST SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-6103
Mailing Address - Country:US
Mailing Address - Phone:727-584-4235
Mailing Address - Fax:727-584-3859
Practice Address - Street 1:168 14TH ST SW
Practice Address - Street 2:SUITE A
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-6103
Practice Address - Country:US
Practice Address - Phone:727-584-4235
Practice Address - Fax:727-584-3859
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN#95461223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics