Provider Demographics
NPI:1710633938
Name:GUERISOLI DENTAL GROUP INC.
Entity Type:Organization
Organization Name:GUERISOLI DENTAL GROUP INC.
Other - Org Name:ASHBY DENTAL IN ELMWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:TRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-722-1724
Mailing Address - Street 1:2507 ASHBY AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2243
Mailing Address - Country:US
Mailing Address - Phone:510-549-0133
Mailing Address - Fax:
Practice Address - Street 1:2507 ASHBY AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2243
Practice Address - Country:US
Practice Address - Phone:510-549-0133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-25
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1588704142OtherDENTISTRY
CA1528460664OtherDENTISTRY