Provider Demographics
NPI:1679987903
Name:BERT AND DAVID ENGSTROM DMD INC
Entity type:Organization
Organization Name:BERT AND DAVID ENGSTROM DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BERT
Authorized Official - Middle Name:FELT
Authorized Official - Last Name:ENGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:559-896-0323
Mailing Address - Street 1:1122 ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:CA
Mailing Address - Zip Code:93662-3257
Mailing Address - Country:US
Mailing Address - Phone:559-896-0323
Mailing Address - Fax:559-896-9251
Practice Address - Street 1:1122 ROSE AVE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3257
Practice Address - Country:US
Practice Address - Phone:559-896-0323
Practice Address - Fax:559-896-9251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-14
Last Update Date:2014-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA335701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty