Provider Demographics
NPI:1164585188
Name:BERBOHM, PETER NELSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:NELSON
Last Name:BERBOHM
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 1:5615 MANZANITA AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-6570
Mailing Address - Country:US
Mailing Address - Phone:916-339-1441
Mailing Address - Fax:916-339-1441
Practice Address - Street 1:5615 MANZANITA AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-6570
Practice Address - Country:US
Practice Address - Phone:916-339-1441
Practice Address - Fax:916-339-1441
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27567122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist