Provider Demographics
NPI:1942260575
Name:BERG, GREGORY TODD (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:TODD
Last Name:BERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1325 QUEENS CT
Mailing Address - Street 2:SUITE A
Mailing Address - City:ST PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-7375
Mailing Address - Country:US
Mailing Address - Phone:636-928-6000
Mailing Address - Fax:636-928-6011
Practice Address - Street 1:1325 QUEENS CT
Practice Address - Street 2:SUITE A
Practice Address - City:ST PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-7375
Practice Address - Country:US
Practice Address - Phone:636-928-6000
Practice Address - Fax:636-928-6011
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0153281223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics