MEDICARE: DOROTHEA J BERRY DDS, 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	52968	CA

General Provider Information

NPI Number	:	1871083709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOROTHEA J BERRY DDS, INC

Provider Business Mailing Address
First Line	:	2690 PACIFIC AVE STE 250
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-2663
Country	:	US
Telephone Number	:	562-240-3054
Fax Number	:	562-317-5260

Provider Business Practice Location Address
First Line	:	2690 PACIFIC AVE STE 250
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-2663
Country	:	US
Telephone Number	:	562-240-3054
Fax Number	:	562-317-5260

Authorized Official
Title or Position	:	OMFS
Name	:	DR. DOROTHEA BERRY
Credential	:	DDS
Telephone Number	:	562-240-3054

Provider Enumeration Date	:	05/16/2018
Last Update Date	:	05/16/2018

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