Healthcare Provider Details

I. General information

NPI: 1275527772
Provider Name (Legal Business Name): STEVEN L BERKE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 NEW LONDON TPKE
NORWICH CT
06360-2624
US

IV. Provider business mailing address

130 NEW LONDON TPKE
NORWICH CT
06360-2624
US

V. Phone/Fax

Practice location:
  • Phone: 860-886-0651
  • Fax: 860-823-1577
Mailing address:
  • Phone: 860-886-0651
  • Fax: 860-823-1577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number006728
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number006728
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: