Provider Demographics
NPI:1407927353
Name:NYBERG, JEROME RAYMOND (DDS)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:RAYMOND
Last Name:NYBERG
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 1:303 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330
Mailing Address - Country:US
Mailing Address - Phone:763-441-9181
Mailing Address - Fax:763-441-3399
Practice Address - Street 1:303 MAIN ST
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330
Practice Address - Country:US
Practice Address - Phone:763-441-9181
Practice Address - Fax:763-441-3399
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7834122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist