Healthcare Provider Details

I. General information

NPI: 1760618052
Provider Name (Legal Business Name): DAVID RANDALL SHERBERG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6882 GULFPORT BLVD S
SOUTH PASADENA FL
33707-2108
US

IV. Provider business mailing address

2 LINCOLN AVE S
ST PETERSBURG FL
33711-5121
US

V. Phone/Fax

Practice location:
  • Phone: 727-384-9655
  • Fax:
Mailing address:
  • Phone: 860-919-0586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number010031
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN20026
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: