Provider Demographics
NPI:1841286655
Name:BERG, GEOFFREY A (DMD)
Entity type:Individual
Prefix:MR
First Name:GEOFFREY
Middle Name:A
Last Name:BERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 WILLETTA ST SW
Mailing Address - Street 2:STE A
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-3846
Mailing Address - Country:US
Mailing Address - Phone:541-928-2301
Mailing Address - Fax:541-928-8493
Practice Address - Street 1:2825 WILLETTA ST SW
Practice Address - Street 2:STE A
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-3846
Practice Address - Country:US
Practice Address - Phone:541-928-2301
Practice Address - Fax:541-928-8493
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD79151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice