Provider Demographics
NPI:1790710325
Name:BERKS ORAL SURGERY LTD
Entity Type:Organization
Organization Name:BERKS ORAL SURGERY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-374-4093
Mailing Address - Street 1:1075 BERKSHIRE BLVD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1264
Mailing Address - Country:US
Mailing Address - Phone:610-374-4093
Mailing Address - Fax:
Practice Address - Street 1:1075 BERKSHIRE BLVD
Practice Address - Street 2:SUITE 800
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1264
Practice Address - Country:US
Practice Address - Phone:610-374-4093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS026002-L1223S0112X
PADS024152-L1223S0112X
PADS-017990-L1223S0112X
PADS-017170-L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU35558Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
PAT28048Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
PAU01377Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
PAT29822Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER