Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DE00008754 | WA |
N | 1223P0221X | Pediatric Dentist | DS029281R | PA |
NPI | 1063574598 |
---|---|
Provider Name | Joel Howard Berg |
First Address | Seattle, WA 98195-7136 |
Second Address | Seattle, WA 98195-7136 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5041066 | (05) | WA |