Provider Demographics
NPI:1598863862
Name:BERARDI, THOMAS R (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:BERARDI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 W MAIN ST APT C5
Mailing Address - Street 2:
Mailing Address - City:TRAPPE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-1980
Mailing Address - Country:US
Mailing Address - Phone:610-322-9855
Mailing Address - Fax:
Practice Address - Street 1:575 W MAIN ST APT C5
Practice Address - Street 2:
Practice Address - City:TRAPPE
Practice Address - State:PA
Practice Address - Zip Code:19426-1980
Practice Address - Country:US
Practice Address - Phone:610-322-9855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019513L1223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
104880Medicare ID - Type Unspecified
T28656Medicare UPIN