Provider Demographics
NPI:1063400273
Name:BERGER, AVRAM SIMEON (DDS)
Entity type:Individual
Prefix:DR
First Name:AVRAM
Middle Name:SIMEON
Last Name:BERGER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:333 KENNEDY DR
Mailing Address - Street 2:SUITE L101
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-3060
Mailing Address - Country:US
Mailing Address - Phone:860-482-3513
Mailing Address - Fax:860-482-3514
Practice Address - Street 1:333 KENNEDY DR
Practice Address - Street 2:SUITE L101
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3060
Practice Address - Country:US
Practice Address - Phone:860-482-3513
Practice Address - Fax:860-482-3514
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT43571223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002043578Medicaid
CT002043578Medicaid
CT190000405Medicare ID - Type UnspecifiedMEDICARE NUMBER