Provider Demographics
NPI:1154771236
Name:BERG, ALICE (RDH)
Entity type:Individual
Prefix:MS
First Name:ALICE
Middle Name:
Last Name:BERG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39793
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98496-3793
Mailing Address - Country:US
Mailing Address - Phone:831-206-7040
Mailing Address - Fax:
Practice Address - Street 1:527 BARNES BLVD
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98438-1304
Practice Address - Country:US
Practice Address - Phone:253-982-5505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13046124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist