MEDICARE: MRS. AMSALE BERHANU-DEMISSIE 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	1223G0001X	General Practice Dentistry	30174	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G9202801	OTHER	CA	DENTICAL
2	G9202802	OTHER	CA	DENTICAL

General Provider Information

NPI Number	:	1891915492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMSALE BERHANU-DEMISSIE DDS.

Provider Business Mailing Address
First Line	:	471 N SAN GORGONIO AVE
Second Line	:
City	:	BANNING
State	:	CA
Zip	:	92220-5523
Country	:	US
Telephone Number	:	951-849-2888
Fax Number	:	951-849-1454

Provider Business Practice Location Address
First Line	:	471 N SAN GORGONIO AVE
Second Line	:
City	:	BANNING
State	:	CA
Zip	:	92220-5523
Country	:	US
Telephone Number	:	951-849-2888
Fax Number	:	951-849-1454

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

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	07/08/2007

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