Provider Demographics
NPI:1396745493
Name:BERG, MALCOLM R (DMD)
Entity type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:R
Last Name:BERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
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Mailing Address - Street 1:3601 LEADVILLE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-6938
Mailing Address - Country:US
Mailing Address - Phone:512-291-0230
Mailing Address - Fax:512-291-0287
Practice Address - Street 1:409 E CROCKETT ST
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:TX
Practice Address - Zip Code:78648-2601
Practice Address - Country:US
Practice Address - Phone:830-875-3521
Practice Address - Fax:830-875-2212
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0094708-01Medicaid
TX1343876OtherUNITED CONCORDIA
TX0094708-02Medicaid
TX806227OtherUNITED CONCORDIA