=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497083448
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMES E BERG DDS MS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2009
-----------------------------------------------------
Last Update Date | 12/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1974 NORTH HURON RIVER DRIVE SUITE #200
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-482-4658
-----------------------------------------------------
Fax | 734-482-0233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1974 NORTH HURON RIVER DRIVE SUITE #200
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-482-4658
-----------------------------------------------------
Fax | 734-482-0233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST OWNER
-----------------------------------------------------
Name | DR. JAMES EDWARD BERG
-----------------------------------------------------
Credential | DDS MS
-----------------------------------------------------
Telephone | 734-482-4658
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------