Provider Demographics
NPI:1679194906
Name:BERTHEOLA, JEFF (DDS)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:BERTHEOLA
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 1:30051 NAVARRO RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:CA
Mailing Address - Zip Code:95410-9722
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 SEQUOIA CIR
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5422
Practice Address - Country:US
Practice Address - Phone:707-964-0242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA307021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice