Healthcare Provider Details

I. General information

NPI: 1669937066
Provider Name (Legal Business Name): H ROBERT VAN DEN BERG DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2019
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S STERLING DR STE 233
MOUNTAIN HOUSE CA
95391-3046
US

IV. Provider business mailing address

1501 BOLLINGER CANYON RD STE A
SAN RAMON CA
94583-1758
US

V. Phone/Fax

Practice location:
  • Phone: 209-650-6560
  • Fax: 209-407-3033
Mailing address:
  • Phone: 925-838-0665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: DR. HARRY ROBERT VAN DEN BERG
Title or Position: PRESIDENT
Credential: DDS
Phone: 209-650-6560