Provider Demographics
NPI:1598806697
Name:BERG, DIANTHA JOAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIANTHA
Middle Name:JOAN
Last Name:BERG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:DIANTHA
Other - Middle Name:JOAN
Other - Last Name:BALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1019 PACIFIC AVE STE 300
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4488
Mailing Address - Country:US
Mailing Address - Phone:253-597-4550
Mailing Address - Fax:253-597-4556
Practice Address - Street 1:1202 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3926
Practice Address - Country:US
Practice Address - Phone:253-471-4743
Practice Address - Fax:253-442-8840
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000061941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6017OtherDSHS PROVIDER ID
WADE00006194OtherDENTIST LICENSE