Provider Demographics
NPI:1215009246
Name:AMY BERHANU DEMISSIE DDS PC
Entity Type:Organization
Organization Name:AMY BERHANU DEMISSIE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMSALE
Authorized Official - Middle Name:BERHANU
Authorized Official - Last Name:DEMISSIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-849-2888
Mailing Address - Street 1:471 N SAN GORGONIO AVE
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220
Mailing Address - Country:US
Mailing Address - Phone:951-849-2888
Mailing Address - Fax:951-849-1454
Practice Address - Street 1:471 N SAN GORGONIO AVE
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220
Practice Address - Country:US
Practice Address - Phone:951-849-2888
Practice Address - Fax:951-849-1454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30174122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty