Provider Demographics
NPI:1609866441
Name:BERMAN, MARK (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:BERMAN
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:PO BOX 166
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:CT
Mailing Address - Zip Code:06524-0166
Mailing Address - Country:US
Mailing Address - Phone:203-278-0885
Mailing Address - Fax:203-389-9484
Practice Address - Street 1:264 AMITY RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2200
Practice Address - Country:US
Practice Address - Phone:203-389-2815
Practice Address - Fax:203-389-9484
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT06766122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist