Provider Demographics
NPI:1326040882
Name:BERG, TAMARA SUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:SUE
Last Name:BERG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:SUE
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:910 S. YUKON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-1801
Mailing Address - Country:US
Mailing Address - Phone:405-354-3763
Mailing Address - Fax:405-354-4041
Practice Address - Street 1:910 S. YUKON PARKWAY
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-1801
Practice Address - Country:US
Practice Address - Phone:405-354-3763
Practice Address - Fax:405-354-4041
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5212122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist