Provider Demographics
NPI:1376764084
Name:BERDAHL, SKY ASHLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:SKY
Middle Name:ASHLEY
Last Name:BERDAHL
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 1:1611 PELHAM PKWY N
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-6416
Mailing Address - Country:US
Mailing Address - Phone:917-406-3773
Mailing Address - Fax:
Practice Address - Street 1:485 1ST AVE APT 5T
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-8627
Practice Address - Country:US
Practice Address - Phone:917-406-3773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP44160390200000X
NY0535901223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program