Healthcare Provider Details

I. General information

NPI: 1164585188
Provider Name (Legal Business Name): PETER NELSON BERBOHM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5615 MANZANITA AVE
CARMICHAEL CA
95608-6570
US

IV. Provider business mailing address

5615 MANZANITA AVE
CARMICHAEL CA
95608-6570
US

V. Phone/Fax

Practice location:
  • Phone: 916-339-1441
  • Fax: 916-339-1441
Mailing address:
  • Phone: 916-339-1441
  • Fax: 916-339-1441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number27567
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: