Provider Demographics
NPI:1710182480
Name:G.L. BERRY D.D.S., A DENTAL CORPORATION
Entity Type:Organization
Organization Name:G.L. BERRY D.D.S., A DENTAL CORPORATION
Other - Org Name:NEIGHBORHOOD FAMILY DENTAL PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLADYS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-362-3540
Mailing Address - Street 1:4655 CASS ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-2809
Mailing Address - Country:US
Mailing Address - Phone:858-362-3540
Mailing Address - Fax:858-362-3544
Practice Address - Street 1:4655 CASS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-2809
Practice Address - Country:US
Practice Address - Phone:858-362-3540
Practice Address - Fax:858-362-3544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA399691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG98442-01OtherHEALTHY FAMILIES
CA1396846036OtherTYPE 1 NPI NUMBER
CAG93297-01OtherDENTI-CAL