MEDICARE: GLADYS LUISA BERRY DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	CA39969	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G9329701	OTHER	CA	DENTICAL
2	1648856	OTHER	CA	UNITED CONCORDIA
3	G9844201	OTHER	CA	HEALTHY FAMILY DELTA

General Provider Information

NPI Number	:	1396846036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLADYS LUISA BERRY DDS

Provider Business Mailing Address
First Line	:	4655 CASS ST
Second Line	:	SUITE 100
City	:	SAN DIEGO
State	:	CA
Zip	:	92109
Country	:	US
Telephone Number	:	858-362-3540
Fax Number	:	858-362-3544

Provider Business Practice Location Address
First Line	:	8788 JAMACHA RD
Second Line	:
City	:	SPRING VALLEY
State	:	CA
Zip	:	91977-4035
Country	:	US
Telephone Number	:	619-515-2555
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/27/2023

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