Provider Demographics
NPI:1255980504
Name:BERNALDO, SAMANTHA (DENTAL HYGIENIST)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BERNALDO
Suffix:
Gender:F
Credentials:DENTAL HYGIENIST
Other - Prefix:MRS
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:BERNALDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DENTAL HYGIENIST
Mailing Address - Street 1:1601 PRECISION PARK LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-1345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:668 THIRD AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910
Practice Address - Country:US
Practice Address - Phone:619-662-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29607124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA29607OtherDENTAL HYGIENE BOARD OF CALIFORNIA