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General NPI Number Information
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NPI Number | 1083021042
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Entity Type | Individual
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Provider Name | JUAN BERNAL GENERAL DENTIST/IMPL
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Gender | Male
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Dates
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Enumeration Date | 07/22/2014
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Last Update Date | 07/22/2014
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Provider Practice Location Address
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Address Line | 3RD STREET AND AVE. A SUITE #8
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City | SAN LUIS
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State | AZ
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Zip | 85349-6173
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Country | US
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Telephone | 928-328-8237
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Fax |
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Provider Business Mailing Address
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Address Line | 3RD STREET AND A SUITE #8
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City | LOS ALGODONES
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State | MEXICALI
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Zip | 21970
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Country | MX
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Telephone | 928-328-8237
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3862950
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License Number State | AZ
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