Provider Demographics
NPI:1992930978
Name:BERRY, MICHELLE NICOLE (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:NICOLE
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 1:123 BERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:ME
Mailing Address - Zip Code:04284-3124
Mailing Address - Country:US
Mailing Address - Phone:207-242-6506
Mailing Address - Fax:
Practice Address - Street 1:ABERDEEN PROVING GROUND DENTAL CLINIC
Practice Address - Street 2:6455 MACHINE STREET, BUILDING 2501
Practice Address - City:ABERDEEN PROVING GROUND
Practice Address - State:MD
Practice Address - Zip Code:21005
Practice Address - Country:US
Practice Address - Phone:410-278-1795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELAN458124Q00000X
MERDH3596124Q00000X
MENOX790124Q00000X
MEDEN4551122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No124Q00000XDental ProvidersDental Hygienist