Provider Demographics
NPI:1083021042
Name:BERNAL, JUAN (GENERAL DENTIST/IMPL)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:
Last Name:BERNAL
Suffix:
Gender:M
Credentials:GENERAL DENTIST/IMPL
Other - Prefix:DR
Other - First Name:CARLOS
Other - Middle Name:
Other - Last Name:CASTANEDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:GENERAL DENTIST
Mailing Address - Street 1:3RD STREET AND A
Mailing Address - Street 2:SUITE #8
Mailing Address - City:LOS ALGODONES
Mailing Address - State:MEXICALI
Mailing Address - Zip Code:21970
Mailing Address - Country:MX
Mailing Address - Phone:928-328-8237
Mailing Address - Fax:
Practice Address - Street 1:3RD STREET AND AVE. A
Practice Address - Street 2:SUITE #8
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349-6173
Practice Address - Country:US
Practice Address - Phone:928-328-8237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ38629501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice