Provider Demographics
NPI:1710995659
Name:BERG, STANLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:
Last Name:BERG
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 1:600 MIDLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GARFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07026
Mailing Address - Country:US
Mailing Address - Phone:973-478-1616
Mailing Address - Fax:973-478-1732
Practice Address - Street 1:600 MIDLAND AVE
Practice Address - Street 2:
Practice Address - City:GARFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07026
Practice Address - Country:US
Practice Address - Phone:973-478-1616
Practice Address - Fax:973-478-1732
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ88591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4676700Medicaid