Provider Demographics
NPI:1740962281
Name:BERMAN, OLIVIA REBECCA (DMD, MS)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:REBECCA
Last Name:BERMAN
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2842
Mailing Address - Country:US
Mailing Address - Phone:310-392-4103
Mailing Address - Fax:
Practice Address - Street 1:323 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2842
Practice Address - Country:US
Practice Address - Phone:310-392-4103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS108727122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist