MEDICARE: GUERISOLI DENTAL GROUP INC.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1588704142	OTHER	CA	DENTISTRY
2	1528460664	OTHER	CA	DENTISTRY

General Provider Information

NPI Number	:	1710633938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUERISOLI DENTAL GROUP INC.

Provider Business Mailing Address
First Line	:	2507 ASHBY AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94705-2243
Country	:	US
Telephone Number	:	510-549-0133
Fax Number	:

Provider Business Practice Location Address
First Line	:	2507 ASHBY AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94705-2243
Country	:	US
Telephone Number	:	510-549-0133
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	TRINA BERTELSON
Credential	:
Telephone Number	:	775-722-1724

Provider Enumeration Date	:	02/25/2022
Last Update Date	:	08/03/2022

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