Provider Demographics
NPI:1265676746
Name:BERK, JASON S (DDS)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:S
Last Name:BERK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3 APRICOT CT
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-8709
Mailing Address - Country:US
Mailing Address - Phone:631-838-9710
Mailing Address - Fax:631-838-9710
Practice Address - Street 1:STONY BROOK UNIVERSITY HOSPITAL
Practice Address - Street 2:MEDICAL STAFF OFFICE T14
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-7148
Practice Address - Country:US
Practice Address - Phone:631-444-2754
Practice Address - Fax:631-444-6031
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY055473-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program