MEDICARE: DR. MADISON NICOLE BERG DMD

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	122300000X	Dentist	2023025477	MO

General Provider Information

NPI Number	:	1942986690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MADISON NICOLE BERG DMD

Provider Business Mailing Address
First Line	:	212 S MERAMEC AVE APT 2104
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63105-3579
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9420 WATSON RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63126-1529
Country	:	US
Telephone Number	:	314-843-0500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2023
Last Update Date	:	06/27/2023

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