Provider Demographics
NPI:1649492885
Name:BERK, MARY ELIZABETH (DDS)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:BERK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W COLLEGE ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1124
Mailing Address - Country:US
Mailing Address - Phone:636-528-8911
Mailing Address - Fax:636-528-3728
Practice Address - Street 1:101 W COLLEGE ST
Practice Address - Street 2:SUITE #3
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1124
Practice Address - Country:US
Practice Address - Phone:636-528-8911
Practice Address - Fax:636-528-3728
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015346122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist