Provider Demographics
NPI:1417107954
Name:BERGE, JENNIFER SUE (RDH, BS)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SUE
Last Name:BERGE
Suffix:
Gender:F
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N BROADWAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-3728
Mailing Address - Country:US
Mailing Address - Phone:507-424-1944
Mailing Address - Fax:
Practice Address - Street 1:120 N BROADWAY
Practice Address - Street 2:SUITE B
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-3728
Practice Address - Country:US
Practice Address - Phone:507-424-1944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-21
Last Update Date:2008-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH7005124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist