Provider Demographics
NPI:1093914582
Name:BEAR VALLEY DENTAL CARE
Entity type:Organization
Organization Name:BEAR VALLEY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERYN
Authorized Official - Middle Name:BURES
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-866-2646
Mailing Address - Street 1:PO BOX 2852
Mailing Address - Street 2:
Mailing Address - City:BIG BEAR LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92315-2852
Mailing Address - Country:US
Mailing Address - Phone:909-866-2646
Mailing Address - Fax:909-866-1796
Practice Address - Street 1:41628 BIG BEAR BLVD
Practice Address - Street 2:
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315
Practice Address - Country:US
Practice Address - Phone:909-866-2646
Practice Address - Fax:909-866-1796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA401101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty