MEDICARE: MATTHEW D. BERG, D.D.S., P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	D11937	MN

General Provider Information

NPI Number	:	1063685493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATTHEW D. BERG, D.D.S., P.A.

Provider Business Mailing Address
First Line	:	2193 SILVER LAKE RD NW
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-5331
Country	:	US
Telephone Number	:	651-633-3116
Fax Number	:

Provider Business Practice Location Address
First Line	:	2193 SILVER LAKE RD NW
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-5331
Country	:	US
Telephone Number	:	651-633-3116
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MATTHEW DOUGLAS BERG
Credential	:	D.D.S.
Telephone Number	:	651-235-9227

Provider Enumeration Date	:	04/07/2008
Last Update Date	:	05/20/2008

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