Provider Demographics
NPI:1699854810
Name:BERKLEY, JEFFREY SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:BERKLEY
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 1:323 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516
Mailing Address - Country:US
Mailing Address - Phone:203-937-7181
Mailing Address - Fax:203-937-1940
Practice Address - Street 1:323 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516
Practice Address - Country:US
Practice Address - Phone:203-937-7181
Practice Address - Fax:203-937-1940
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT70261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002070267Medicaid
CTT23252Medicare UPIN
CT002070267Medicaid