Provider Demographics
NPI:1669840518
Name:BERG, KENNETH RICHARD (DMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RICHARD
Last Name:BERG
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 1:3550 SW BOND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4507
Mailing Address - Country:US
Mailing Address - Phone:503-688-6719
Mailing Address - Fax:
Practice Address - Street 1:3550 SW BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4507
Practice Address - Country:US
Practice Address - Phone:503-688-6719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD32081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD3208OtherDENTAL LICENSE