Healthcare Provider Details

I. General information

NPI: 1508875907
Provider Name (Legal Business Name): RICHARD BERG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1181 OLD COUNTRY RD SUITE 4
PLAINVIEW NY
11803-5018
US

IV. Provider business mailing address

1181 OLD COUNTRY RD SUITE 4
PLAINVIEW NY
11803-5018
US

V. Phone/Fax

Practice location:
  • Phone: 516-822-7880
  • Fax: 516-822-5010
Mailing address:
  • Phone: 516-822-7880
  • Fax: 516-822-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number026825-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0038659994
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: