Provider Demographics
NPI:1770195810
Name:BERG, PATRICK THOMAS (DDS)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:THOMAS
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 1:2463 PORTSIDE LN APT 21
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-9693
Mailing Address - Country:US
Mailing Address - Phone:414-510-1128
Mailing Address - Fax:
Practice Address - Street 1:2719 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-5546
Practice Address - Country:US
Practice Address - Phone:920-686-2333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002406-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty