Provider Demographics
NPI:1124317375
Name:DAVID BERNAL DDS, PLLC
Entity type:Organization
Organization Name:DAVID BERNAL DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:409-853-3100
Mailing Address - Street 1:7675 MEMORIAL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640
Mailing Address - Country:US
Mailing Address - Phone:409-853-3100
Mailing Address - Fax:409-727-3249
Practice Address - Street 1:7675 MEMORIAL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640
Practice Address - Country:US
Practice Address - Phone:409-853-3100
Practice Address - Fax:409-727-3249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24729122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209014402Medicaid