Provider Demographics
NPI:1578045159
Name:BERNAL, CARLOS ALONSO (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:ALONSO
Last Name:BERNAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E EVERGREEN ST APT A
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-4422
Mailing Address - Country:US
Mailing Address - Phone:817-996-9142
Mailing Address - Fax:
Practice Address - Street 1:327 NW LOOP 410 STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-5304
Practice Address - Country:US
Practice Address - Phone:844-776-4802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX344861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX34486OtherTSBDE