Healthcare Provider Details

I. General information

NPI: 1740978246
Provider Name (Legal Business Name): JUSTIN LEROY BERMUDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/21/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 ALHAMBRA BLVD
SACRAMENTO CA
95816-3806
US

IV. Provider business mailing address

630 ALHAMBRA BLVD
SACRAMENTO CA
95816-3806
US

V. Phone/Fax

Practice location:
  • Phone: 916-201-0074
  • Fax:
Mailing address:
  • Phone: 916-201-0074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS109747
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: