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399 E Highland Ave Suite 120 San Bernardino CA 92404-3808 | |
| (909) 881-0645 | |
| (909) 881-4957 |
| Full Name | |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 399 E Highland Ave, San Bernardino, California |
| Authorized Official Name and Position | Antoine O Sourialle (OWNER) |
| Authorized Official Contact | 9098810645 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
399 E Highland Ave Suite 120 San Bernardino CA 92404-3808 Ph: (909) 881-0645 | 399 E Highland Ave Suite 120 San Bernardino CA 92404-3808 Ph: (909) 881-0645 |
| NPI Number | 1588715031 |
|---|---|
| Provider Enumeration Date | 01/12/2007 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1588715031 | NPI | - | NPPES |
| 10490 | Other | CA | PACIFICARE HMO |
| 20088156 | Other | CA | PREVIOUS EIN |
| 004239 | Other | CA | LIBERTY DENTAL HMO |
| B44093-01 | Other | CA | DELTA HEALTHY FAMILY |
| DJ61 | Other | CA | SMILESAVER HMO |
| G92830-01 | Other | CA | DENTI-CAL |
| 007367 | Other | CA | PMI HMO |
| 50755-1 | Other | CA | BLUE SHIELD |
| 971330 | Other | CA | UNITED CONCORDIA HMO |
| 97036530 | Other | CA | SAFEGUARD HMO |
| 134921 | Other | CA | DHS HMO |
| F0275 | Other | CA | GOLDEN WEST HMO |
| 0010973 | Other | CA | ASSURANT HMO |
| P006271 | Other | CA | WELLPOINT HMO |
| 0004636 | Other | CA | MANAGED DENTAL HMO |
| 01628 | Other | CA | WESTERN DENTAL HMO |
| 210745 | Other | CA | CIGNA HMO |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 44093 (California) | Primary |
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