Provider Demographics
NPI:1477557163
Name:BERG, JOHN W (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:BERG
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 1:1139 N BRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91202-3000
Mailing Address - Country:US
Mailing Address - Phone:818-507-1144
Mailing Address - Fax:818-242-6073
Practice Address - Street 1:1139 N BRAND BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-3000
Practice Address - Country:US
Practice Address - Phone:818-507-1144
Practice Address - Fax:818-242-6073
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-11-07
Deactivation Date:2006-03-15
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
CA198401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice