Provider Demographics
NPI:1811061849
Name:BERG, MATHEW ARNOLD (DMD)
Entity type:Individual
Prefix:DR
First Name:MATHEW
Middle Name:ARNOLD
Last Name:BERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 W. 6TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074
Mailing Address - Country:US
Mailing Address - Phone:405-707-6106
Mailing Address - Fax:405-707-0602
Practice Address - Street 1:510 S. DUCK
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074
Practice Address - Country:US
Practice Address - Phone:405-707-6106
Practice Address - Fax:405-707-0602
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK57511223G0001X
TX238281223G0001X
LA61101223G0001X
IA087621223G0001X
OH30-0232691223G0001X
IN12011461A1223G0001X
AR37371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice