Healthcare Provider Details

I. General information

NPI: 1487955076
Provider Name (Legal Business Name): LAURA ELLEN BERGER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 BARNES RD SUITE 207
WALLINGFORD CT
06492-1832
US

IV. Provider business mailing address

25 NEEDHAM ST
NEWTON MA
02461-1615
US

V. Phone/Fax

Practice location:
  • Phone: 203-678-1201
  • Fax: 203-678-1209
Mailing address:
  • Phone: 617-964-6681
  • Fax: 617-630-0141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number007819
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: