MEDICARE: BRIDENT DDS PC

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

General Provider Information

NPI Number	:	1629762455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDENT DDS PC

Provider Business Mailing Address
First Line	:	530 S MAIN ST
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-4525
Country	:	US
Telephone Number	:	714-480-3000
Fax Number	:	714-571-6445

Provider Business Practice Location Address
First Line	:	9021 TEHAMA RIDGE PKWY
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76177-2002
Country	:	US
Telephone Number	:	714-571-2140
Fax Number	:	714-571-6445

Authorized Official
Title or Position	:	EXECUTIVE VICE PRESIDENT
Name	:	BILL DEMBERECKYJ
Credential	:
Telephone Number	:	714-571-6445

Provider Enumeration Date	:	06/05/2023
Last Update Date	:	06/05/2023

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