Basic Information
| Provider Information | |||||||||
| NPI: | 1003058488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERMUDEZ | ||||||||
| FirstName: | LINA | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 30 | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135289311 | ||||||||
| FaxNumber: | 4136440274 | ||||||||
| Practice Location | |||||||||
| Address1: | 343 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135285565 | ||||||||
| FaxNumber: | 4135285564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 10558 | MA | N | Dental Providers | Dentist | General Practice | 1223G0001X | DL13088 | MA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | DL10558 | 01 | MA | MASSACHUSETTS LICENSE | OTHER | 110114758A | 05 | MA | MEDICAID |