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General NPI Number Information
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NPI Number | 1710182480
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Entity Type | Organization
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Legal Business Name | G.L. BERRY D.D.S., A DENTAL CORPORATION
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Dates
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Enumeration Date | 06/20/2007
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Last Update Date | 08/13/2007
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Provider Practice Location Address
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Address Line | 4655 CASS ST SUITE 100
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City | SAN DIEGO
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State | CA
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Zip | 92109-2809
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Country | US
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Telephone | 858-362-3540
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Fax | 858-362-3544
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Provider Business Mailing Address
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Address Line | 4655 CASS ST SUITE 100
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City | SAN DIEGO
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State | CA
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Zip | 92109-2809
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Country | US
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Telephone | 858-362-3540
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Fax | 858-362-3544
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GLADYS L. BERRY
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Credential | D.D.S.
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Telephone | 858-362-3540
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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 | 39969
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License Number State | CA
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