Provider Demographics
NPI:1720066517
Name:BERG, PAUL EUGENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:EUGENE
Last Name:BERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6519 NICOLLET AVE S
Mailing Address - Street 2:#205
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1669
Mailing Address - Country:US
Mailing Address - Phone:612-861-7141
Mailing Address - Fax:
Practice Address - Street 1:6519 NICOLLET AVE S
Practice Address - Street 2:#205
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1669
Practice Address - Country:US
Practice Address - Phone:612-861-7141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN91621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice