Healthcare Provider Details

I. General information

NPI: 1285719468
Provider Name (Legal Business Name): BRIAN C BERG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 HOSPITAL CIR
CHOCTAW MS
39350-6781
US

IV. Provider business mailing address

210 HOSPITAL CIR
CHOCTAW MS
39350-6781
US

V. Phone/Fax

Practice location:
  • Phone: 601-389-4033
  • Fax: 601-389-4031
Mailing address:
  • Phone: 601-389-4033
  • Fax: 601-389-4031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number225786
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: