Provider Demographics
NPI:1639432776
Name:BERTRAND, THIKAMPHAA (DDS)
Entity type:Individual
Prefix:DR
First Name:THIKAMPHAA
Middle Name:
Last Name:BERTRAND
Suffix:
Gender:
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1012
Mailing Address - Country:US
Mailing Address - Phone:703-615-0457
Mailing Address - Fax:
Practice Address - Street 1:1250 N MILL ST STE 100
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-6305
Practice Address - Country:US
Practice Address - Phone:630-995-9107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-22
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0210026821223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics