Provider Demographics
NPI:1881349108
Name:BERK, DANIEL DIXON
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:DIXON
Last Name:BERK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 27TH AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-5128
Mailing Address - Country:US
Mailing Address - Phone:406-926-2940
Mailing Address - Fax:406-926-2944
Practice Address - Street 1:2230 27TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-5128
Practice Address - Country:US
Practice Address - Phone:406-926-2940
Practice Address - Fax:406-926-2944
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6253183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT6253OtherMONTANA STATE LICENSE