Provider Demographics
NPI:1992026041
Name:BERSON, PAUL JEFFERY
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JEFFERY
Last Name:BERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 WALNUT STREET
Mailing Address - Street 2:SUITE 704 THE DENTAL SPA
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-2904
Mailing Address - Country:US
Mailing Address - Phone:215-567-0800
Mailing Address - Fax:215-567-6244
Practice Address - Street 1:1601 WALNUT STREET
Practice Address - Street 2:SUITE 704
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-2904
Practice Address - Country:US
Practice Address - Phone:215-567-0800
Practice Address - Fax:215-567-6244
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS018660-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice