Provider Demographics
NPI:1942378419
Name:MARK D. BERARD, DDS, PC
Entity Type:Organization
Organization Name:MARK D. BERARD, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:BERARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:616-392-2853
Mailing Address - Street 1:203 WEST 30TH STREET
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423
Mailing Address - Country:US
Mailing Address - Phone:616-392-2853
Mailing Address - Fax:616-392-2568
Practice Address - Street 1:203 WEST 30TH STREET
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423
Practice Address - Country:US
Practice Address - Phone:616-392-2853
Practice Address - Fax:616-392-2568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI020978145331223G0001X
MI29010191281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID145330OtherBCBSM
1884295OtherUNITED CONCORDIA
D801446OtherBCBSM
625904OtherUNITED CONCORDIA