Provider Demographics
NPI:1356349682
Name:BERRY, ERIC LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:LEE
Last Name:BERRY
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 1:1800 FORTINO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1890
Mailing Address - Country:US
Mailing Address - Phone:719-545-1400
Mailing Address - Fax:719-545-5153
Practice Address - Street 1:1800 FORTINO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1890
Practice Address - Country:US
Practice Address - Phone:719-545-1400
Practice Address - Fax:719-545-5153
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO105682122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist