Provider Demographics
NPI:1467004762
Name:BERNARDO, MARC ANTHONY (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:ANTHONY
Last Name:BERNARDO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:MARC
Other - Middle Name:ANTHONY ALVAREZ
Other - Last Name:BERNARDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 668
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92556-0668
Mailing Address - Country:US
Mailing Address - Phone:951-242-6088
Mailing Address - Fax:
Practice Address - Street 1:1200 E WASHINGTON ST STE F2
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-6499
Practice Address - Country:US
Practice Address - Phone:909-422-0885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1040481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice