Provider Demographics
NPI:1902908783
Name:BERMUDEZ, LUIS MANUEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:MANUEL
Last Name:BERMUDEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 TRUEMPER ST BLDG 6418
Mailing Address - Street 2:
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5511
Mailing Address - Country:US
Mailing Address - Phone:210-292-0676
Mailing Address - Fax:
Practice Address - Street 1:1615 TRUEMPER ST BLDG 6418
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5511
Practice Address - Country:US
Practice Address - Phone:787-787-9469
Practice Address - Fax:210-292-0676
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice