Provider Demographics
NPI:1649491093
Name:BARRETO, FERNANDO (DDS)
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:BARRETO
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 1:1612 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-4227
Mailing Address - Country:US
Mailing Address - Phone:213-250-3767
Mailing Address - Fax:213-250-7663
Practice Address - Street 1:1612 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-4227
Practice Address - Country:US
Practice Address - Phone:213-250-3767
Practice Address - Fax:213-250-7663
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26336122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB26336Medicaid