Provider Demographics
NPI:1427544618
Name:ANCHETA, BERNARD TESORERO III
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:TESORERO
Last Name:ANCHETA
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5055 LINDELL RD APT 2117
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-1266
Mailing Address - Country:US
Mailing Address - Phone:650-245-3649
Mailing Address - Fax:
Practice Address - Street 1:2585 S NELLIS BLVD STE 6
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7548
Practice Address - Country:US
Practice Address - Phone:702-641-0481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV70921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice