Provider Demographics
NPI:1124372602
Name:BERRY, CONSTANCE VAN DORP (RDHAP)
Entity Type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:VAN DORP
Last Name:BERRY
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 W FLOWER CIR N
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-5836
Mailing Address - Country:US
Mailing Address - Phone:909-568-8071
Mailing Address - Fax:
Practice Address - Street 1:199 PACIFIC VIEW LN
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-7725
Practice Address - Country:US
Practice Address - Phone:909-568-8071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA239124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist