MEDICARE: HARRY ROBERT VAN DEN BERG DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	45210	CA

General Provider Information

NPI Number	:	1174727648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HARRY ROBERT VAN DEN BERG DDS

Provider Business Mailing Address
First Line	:	1501 BOLLINGER CANYON RD
Second Line	:	SUITE A
City	:	SAN RAMON
State	:	CA
Zip	:	94583-1758
Country	:	US
Telephone Number	:	925-838-0665
Fax Number	:	925-838-0668

Provider Business Practice Location Address
First Line	:	1501 BOLLINGER CANYON RD STE A
Second Line	:
City	:	SAN RAMON
State	:	CA
Zip	:	94583-1758
Country	:	US
Telephone Number	:	925-838-0665
Fax Number	:	925-523-6580

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	05/23/2023

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