Provider Demographics
NPI:1881764389
Name:BERRY, JAMES B
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:B
Last Name:BERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 KEARNY VILLA RD
Mailing Address - Street 2:STE #116
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-571-3534
Mailing Address - Fax:858-571-5826
Practice Address - Street 1:4540 KEARNY VILLA RD
Practice Address - Street 2:STE #116
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-571-3534
Practice Address - Fax:858-571-5826
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD4318941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice