Provider Demographics
NPI:1053322859
Name:BERNS, JACK DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:DAVID
Last Name:BERNS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 YORK ST
Mailing Address - Street 2:SUITE 2J
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5614
Mailing Address - Country:US
Mailing Address - Phone:203-777-2513
Mailing Address - Fax:203-776-1714
Practice Address - Street 1:123 YORK ST
Practice Address - Street 2:SUITE 2J
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5614
Practice Address - Country:US
Practice Address - Phone:203-777-2513
Practice Address - Fax:203-776-1714
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT37271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice