Provider Demographics
NPI:1497775530
Name:BERRY, MICHAEL W (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:BERRY
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 1:110 E ROLLINS ST
Mailing Address - Street 2:P.O. BOX 517
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-2269
Mailing Address - Country:US
Mailing Address - Phone:660-263-1133
Mailing Address - Fax:660-263-9181
Practice Address - Street 1:110 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-2269
Practice Address - Country:US
Practice Address - Phone:660-263-1133
Practice Address - Fax:660-263-9181
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE0148451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice