Provider Demographics
NPI:1659861425
Name:DOROTHEA J BERRY DDS, INC
Entity Type:Organization
Organization Name:DOROTHEA J BERRY DDS, INC
Other - Org Name:SUNCOAST ORAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OMFS
Authorized Official - Prefix:DR
Authorized Official - First Name:DOROTHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-240-3054
Mailing Address - Street 1:2690 PACIFIC AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2663
Mailing Address - Country:US
Mailing Address - Phone:562-240-3054
Mailing Address - Fax:562-317-5260
Practice Address - Street 1:27462 CALLE ARROYO STE 46B
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-6762
Practice Address - Country:US
Practice Address - Phone:562-240-3054
Practice Address - Fax:562-317-5260
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOROTHEA J BERRY DDS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA529681223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty