Provider Demographics
NPI:1851433510
Name:BERDY DENTAL GROUP
Entity Type:Organization
Organization Name:BERDY DENTAL GROUP
Other - Org Name:DR'S SCOTT, WATSON, MILLER & BERDY, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BERDY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:904-389-1376
Mailing Address - Street 1:1511 STOCKTON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4521
Mailing Address - Country:US
Mailing Address - Phone:904-389-1376
Mailing Address - Fax:904-389-1522
Practice Address - Street 1:1511 STOCKTON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4521
Practice Address - Country:US
Practice Address - Phone:904-389-1376
Practice Address - Fax:904-389-1522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X, 1223P0300X
FL59591223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty