1487955076 NPI number — LAURA ELLEN BERGER DDS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487955076 NPI number — LAURA ELLEN BERGER DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGER
Provider First Name:
LAURA
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487955076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 NEEDHAM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02461-1615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-964-6681
Provider Business Mailing Address Fax Number:
617-630-0141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
85 BARNES RD
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
WALLINGFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06492-1832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-678-1201
Provider Business Practice Location Address Fax Number:
203-678-1209
Provider Enumeration Date:
11/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  007819 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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