Provider Demographics
NPI:1790725489
Name:BERGER, TIMOTHY STEPHAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:STEPHAN
Last Name:BERGER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 SAINT JOE RIVER DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1434
Mailing Address - Country:US
Mailing Address - Phone:260-482-4202
Mailing Address - Fax:260-482-5232
Practice Address - Street 1:1620 SAINT JOE RIVER DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1434
Practice Address - Country:US
Practice Address - Phone:260-482-4202
Practice Address - Fax:260-482-5232
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120086761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice