Provider Demographics
NPI:1346580974
Name:THEBERGE, NICHOLAS PETER (DDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:PETER
Last Name:THEBERGE
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 1:285 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01301-2608
Mailing Address - Country:US
Mailing Address - Phone:413-774-2961
Mailing Address - Fax:
Practice Address - Street 1:285 HIGH ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301-2608
Practice Address - Country:US
Practice Address - Phone:413-774-2961
Practice Address - Fax:413-773-3076
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857508204E00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program