=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851576078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY I. BERGER DMD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2008
-----------------------------------------------------
Last Update Date | 01/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17270 HAWTHORNE BLVD
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90504-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-542-7331
-----------------------------------------------------
Fax | 310-542-5154
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17270 HAWTHORNE BLVD
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90504-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-542-7331
-----------------------------------------------------
Fax | 310-542-5154
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREATMENT COORDINATOR
-----------------------------------------------------
Name | ANGIE NILE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-542-7331
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 26035
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------