Provider Demographics
NPI:1639276355
Name:BERSON, EVAN LYLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:LYLE
Last Name:BERSON
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 1:401 ANDREW RD
Mailing Address - Street 2:
Mailing Address - City:MERION STATION
Mailing Address - State:PA
Mailing Address - Zip Code:19066-1327
Mailing Address - Country:US
Mailing Address - Phone:610-667-1003
Mailing Address - Fax:
Practice Address - Street 1:301 E CITY AVE
Practice Address - Street 2:SUTIE T2
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1708
Practice Address - Country:US
Practice Address - Phone:610-667-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-024034-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice