MEDICARE: RONALD LEWIS BERRY DMD

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)	2168-85	MS
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DN11031	FL
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	23704	TX

General Provider Information

NPI Number	:	1912998410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD LEWIS BERRY DMD

Provider Business Mailing Address
First Line	:	3903 WISEMAN BLVD STE 114
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-4401
Country	:	US
Telephone Number	:	210-256-9467
Fax Number	:	210-256-9468

Provider Business Practice Location Address
First Line	:	3903 WISEMAN BLVD STE 114
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78251-4401
Country	:	US
Telephone Number	:	210-256-9467
Fax Number	:	210-256-9468

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

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	09/18/2008

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