Provider Demographics
NPI:1013448034
Name:DR. BERRY PC
Entity type:Organization
Organization Name:DR. BERRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF DENTAL SURGERY
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-691-0267
Mailing Address - Street 1:11825 STATE ROUTE 40
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DUNLAP
Mailing Address - State:IL
Mailing Address - Zip Code:61525-8842
Mailing Address - Country:US
Mailing Address - Phone:309-839-9941
Mailing Address - Fax:309-839-9943
Practice Address - Street 1:1660 S ALBION ST
Practice Address - Street 2:SUITE 1008
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80222-4008
Practice Address - Country:US
Practice Address - Phone:303-691-0267
Practice Address - Fax:303-691-0268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-22
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7991122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1003998485OtherINDIVIDUAL NPI NUMBER
CO1962765651OtherDR. BERRY PC ORGANIZATION (TYPE 2) NPI NUMBER