Provider Demographics
NPI:1760426159
Name:BERRY JR, JOHN CHESTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHESTER
Last Name:BERRY JR
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 1:632 GARY ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-2202
Mailing Address - Country:US
Mailing Address - Phone:919-682-4861
Mailing Address - Fax:919-688-4861
Practice Address - Street 1:632 GARY ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-2202
Practice Address - Country:US
Practice Address - Phone:919-682-4861
Practice Address - Fax:919-688-4861
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC44251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD402554OtherCIGNA
NC111150OtherAETNA PROVIDER NUMBER
NC8990679Medicaid
NC90679OtherBLUE CROSS PROVIDER NUMBE