Provider Demographics
NPI:1477656015
Name:BERTETTI, RICHARD DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DAVID
Last Name:BERTETTI
Suffix:
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 1:3501 BEHRMAN PL
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114-8201
Mailing Address - Country:US
Mailing Address - Phone:917-226-6003
Mailing Address - Fax:
Practice Address - Street 1:3501 BEHRMAN PL
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-8201
Practice Address - Country:US
Practice Address - Phone:917-226-6003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA55491223S0112X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5549OtherLA STATE DENTAL LICENSE
LA5549OtherLA STATE DENTAL LICENSE
201548345Medicare UPIN