Provider Demographics
NPI:1063685493
Name:MATTHEW D. BERG, D.D.S., P.A.
Entity type:Organization
Organization Name:MATTHEW D. BERG, D.D.S., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-235-9227
Mailing Address - Street 1:2193 SILVER LAKE RD NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-5331
Mailing Address - Country:US
Mailing Address - Phone:651-633-3116
Mailing Address - Fax:
Practice Address - Street 1:2193 SILVER LAKE RD NW
Practice Address - Street 2:
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-5331
Practice Address - Country:US
Practice Address - Phone:651-633-3116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11937261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental