Provider Demographics
NPI:1063574598
Name:BERG, JOEL HOWARD (DDS)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:HOWARD
Last Name:BERG
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:BOX 357136
Mailing Address - Street 2:1959 NE PACIFIC ST B242
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-7136
Mailing Address - Country:US
Mailing Address - Phone:206-543-4885
Mailing Address - Fax:206-616-7470
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:B242
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-7136
Practice Address - Country:US
Practice Address - Phone:206-543-4885
Practice Address - Fax:206-616-7470
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000087541223P0221X
PADS029281R1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5041066Medicaid