Healthcare Provider Details

I. General information

NPI: 1164556668
Provider Name (Legal Business Name): IGNACIO Z. BERNARDO, JR., D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 3RD AVE
MONTGOMERY WV
25136-2222
US

IV. Provider business mailing address

202 3RD AVE
MONTGOMERY WV
25136-2222
US

V. Phone/Fax

Practice location:
  • Phone: 304-442-5136
  • Fax:
Mailing address:
  • Phone: 304-442-5136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3257
License Number StateWV

VIII. Authorized Official

Name: DR. IGNACIO ZAPANTA BERNARDO JR.
Title or Position: DENTIST
Credential: D.D.S.
Phone: 304-442-5136