Healthcare Provider Details

I. General information

NPI: 1215345145
Provider Name (Legal Business Name): JEFFREY BERT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

561 SAYBROOK RD
MIDDLETOWN CT
06457-4791
US

IV. Provider business mailing address

561 SAYBROOK RD
MIDDLETOWN CT
06457-4791
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-8004
  • Fax: 860-346-9131
Mailing address:
  • Phone: 860-347-8004
  • Fax: 860-346-9131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5368
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: