Provider Demographics
NPI:1104434695
Name:BERTULFO, ADRIAN
Entity type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:BERTULFO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 ADVENTUROUS SHIELD DR
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-5409
Mailing Address - Country:US
Mailing Address - Phone:214-425-8576
Mailing Address - Fax:
Practice Address - Street 1:900 S PRESTON RD
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-5143
Practice Address - Country:US
Practice Address - Phone:469-459-0403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363381223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice