Provider Demographics
NPI:1922098755
Name:PERRY, BERTEL THORWALDSEN III (DMD)
Entity Type:Individual
Prefix:DR
First Name:BERTEL
Middle Name:THORWALDSEN
Last Name:PERRY
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:CANDOR
Mailing Address - State:NY
Mailing Address - Zip Code:13743-0071
Mailing Address - Country:US
Mailing Address - Phone:607-659-4050
Mailing Address - Fax:607-659-4644
Practice Address - Street 1:12 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CANDOR
Practice Address - State:NY
Practice Address - Zip Code:13743-0071
Practice Address - Country:US
Practice Address - Phone:607-659-4050
Practice Address - Fax:607-659-4644
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0388581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice