Provider Demographics
NPI:1134736366
Name:BERSABA, MEL-ANIZI ABANTE (DDS)
Entity type:Individual
Prefix:DR
First Name:MEL-ANIZI
Middle Name:ABANTE
Last Name:BERSABA
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 1:12481 KOKOMO CT
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-6780
Mailing Address - Country:US
Mailing Address - Phone:775-303-3404
Mailing Address - Fax:
Practice Address - Street 1:11092 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1706
Practice Address - Country:US
Practice Address - Phone:909-558-8187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1021801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice