Healthcare Provider Details

I. General information

NPI: 1063574598
Provider Name (Legal Business Name): JOEL HOWARD BERG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST B242
SEATTLE WA
98195-7136
US

IV. Provider business mailing address

BOX 357136 1959 NE PACIFIC ST B242
SEATTLE WA
98195-7136
US

V. Phone/Fax

Practice location:
  • Phone: 206-543-4885
  • Fax: 206-616-7470
Mailing address:
  • Phone: 206-543-4885
  • Fax: 206-616-7470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDE00008754
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDS029281R
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: