Provider Demographics
NPI:1043318330
Name:BEREST, ALEX BOHDAN (DDS)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:BOHDAN
Last Name:BEREST
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 HORNBLEND
Mailing Address - Street 2:STE A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-4057
Mailing Address - Country:US
Mailing Address - Phone:858-270-6855
Mailing Address - Fax:858-270-6987
Practice Address - Street 1:945 HORNBLEND
Practice Address - Street 2:STE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-4057
Practice Address - Country:US
Practice Address - Phone:858-270-6855
Practice Address - Fax:858-270-6987
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22474122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA429481OtherUNITED CONCORDIA
CAB2247401OtherDENTICAL