Healthcare Provider Details

I. General information

NPI: 1063596088
Provider Name (Legal Business Name): MICHAEL W BERRY DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E ROLLINS ST
MOBERLY MO
65270-2269
US

IV. Provider business mailing address

110 E ROLLINS ST P.O. BOX 517
MOBERLY MO
65270-2269
US

V. Phone/Fax

Practice location:
  • Phone: 660-263-1133
  • Fax: 660-263-9181
Mailing address:
  • Phone: 660-263-1133
  • Fax: 660-263-9181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number014845
License Number StateMO

VIII. Authorized Official

Name: DR. MICHAEL WAYNE BERRY
Title or Position: DENTIST OWNER
Credential: D.D.S.
Phone: 660-263-1133