Provider Demographics
NPI:1699414334
Name:BERRY, RENATA (DMD)
Entity type:Individual
Prefix:
First Name:RENATA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 LENOX AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-1802
Mailing Address - Country:US
Mailing Address - Phone:212-939-1000
Mailing Address - Fax:
Practice Address - Street 1:385 W BROADWAY
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2217
Practice Address - Country:US
Practice Address - Phone:617-268-8242
Practice Address - Fax:617-268-1973
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1859926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program