Provider Demographics
NPI:1134131477
Name:BERG, NORMAN KENT (DDS)
Entity Type:Individual
Prefix:
First Name:NORMAN
Middle Name:KENT
Last Name:BERG
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:PO BOX 297
Mailing Address - Street 2:1040 TRUMP ROAD ST A
Mailing Address - City:CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:44615
Mailing Address - Country:US
Mailing Address - Phone:330-627-5666
Mailing Address - Fax:330-627-7889
Practice Address - Street 1:1040 TRUMP ROAD
Practice Address - Street 2:ST A
Practice Address - City:CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:44615
Practice Address - Country:US
Practice Address - Phone:330-627-5666
Practice Address - Fax:330-627-7889
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH13634122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0163844Medicaid