Provider Demographics
NPI:1891915492
Name:BERHANU-DEMISSIE, AMSALE (DDS)
Entity Type:Individual
Prefix:MRS
First Name:AMSALE
Middle Name:
Last Name:BERHANU-DEMISSIE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:BERHANU-DEMISSIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:471 N SAN GORGONIO AVE
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-5523
Mailing Address - Country:US
Mailing Address - Phone:951-849-2888
Mailing Address - Fax:951-849-1454
Practice Address - Street 1:471 N SAN GORGONIO AVE
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-5523
Practice Address - Country:US
Practice Address - Phone:951-849-2888
Practice Address - Fax:951-849-1454
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9202801OtherDENTICAL
CAG9202802OtherDENTICAL