Provider Demographics
NPI:1588623094
Name:BERK, MADELINE D (DMD)
Entity Type:Individual
Prefix:DR
First Name:MADELINE
Middle Name:D
Last Name:BERK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17040 AYERS RD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34604-6806
Mailing Address - Country:US
Mailing Address - Phone:352-537-5027
Mailing Address - Fax:844-290-8521
Practice Address - Street 1:17040 AYERS RD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34604-6806
Practice Address - Country:US
Practice Address - Phone:352-537-5027
Practice Address - Fax:844-290-8521
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN153181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3500047-00Medicaid
FLU846860001Medicare UPIN
FL3500047-00Medicaid