Provider Demographics
NPI:1255485736
Name:BERMUDEZ, MARIA LUISA (DMD)
Entity Type:Individual
Prefix:MRS
First Name:MARIA LUISA
Middle Name:
Last Name:BERMUDEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:M. LUISA
Other - Middle Name:
Other - Last Name:BERMUDEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:755 SO. FAIRMONT
Mailing Address - Street 2:SUITE D
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240
Mailing Address - Country:US
Mailing Address - Phone:209-369-1959
Mailing Address - Fax:209-369-2943
Practice Address - Street 1:755 SO. FAIRMONT
Practice Address - Street 2:SUITE D
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240
Practice Address - Country:US
Practice Address - Phone:209-369-1959
Practice Address - Fax:209-369-2943
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB37632122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist