Healthcare Provider Details

I. General information

NPI: 1699911867
Provider Name (Legal Business Name): MARC JORDAN BERGER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2008
Last Update Date: 12/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MADISON AVENUE
LAKEWOOD NJ
08701
US

IV. Provider business mailing address

301 MADISON AVENUE
LAKEWOOD NJ
08701
US

V. Phone/Fax

Practice location:
  • Phone: 732-367-3303
  • Fax: 732-905-9210
Mailing address:
  • Phone: 732-367-3303
  • Fax: 732-905-9210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD102390800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: