MEDICARE: BERNARD TESORERO ANCHETA III

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	1223G0001X	General Practice Dentistry	7092	NV

General Provider Information

NPI Number	:	1427544618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERNARD TESORERO ANCHETA III

Provider Business Mailing Address
First Line	:	5055 LINDELL RD APT 2117
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-1266
Country	:	US
Telephone Number	:	650-245-3649
Fax Number	:

Provider Business Practice Location Address
First Line	:	2585 S NELLIS BLVD STE 6
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-7548
Country	:	US
Telephone Number	:	702-641-0481
Fax Number	:

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

Provider Enumeration Date	:	07/10/2018
Last Update Date	:	07/10/2018

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