Provider Demographics
NPI:1275527772
Name:BERKE, STEVEN L (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:L
Last Name:BERKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 NEW LONDON TPKE
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2624
Mailing Address - Country:US
Mailing Address - Phone:860-886-0651
Mailing Address - Fax:860-823-1577
Practice Address - Street 1:130 NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2624
Practice Address - Country:US
Practice Address - Phone:860-886-0651
Practice Address - Fax:860-823-1577
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0067281223P0106X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT190000670OtherMEDICARE
CT020006728CT01OtherBC/BS PROVIDER ID #
CT5477144OtherAETNA MEDICAL PROVIDER ID
CT004083333Medicaid
CTT22802Medicare UPIN