Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 14352 | MO |
NPI | 1134217318 |
---|---|
Provider Name | Mark S Berg |
First Address | St Louis, MO 63141 |
Second Address | St Louis, MO 63141 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2006 |
Last Update Date | 08/07/2007 |