Provider Demographics
NPI:1912998410
Name:BERRY, RONALD LEWIS (DMD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:LEWIS
Last Name:BERRY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903 WISEMAN BLVD STE 114
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-4401
Mailing Address - Country:US
Mailing Address - Phone:210-256-9467
Mailing Address - Fax:210-256-9468
Practice Address - Street 1:3903 WISEMAN BLVD STE 114
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4401
Practice Address - Country:US
Practice Address - Phone:210-256-9467
Practice Address - Fax:210-256-9468
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2168-851223S0112X
FLDN110311223S0112X
TX237041223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery