Provider Demographics
NPI:1538360342
Name:THEBERGE, MAURICE GEORGE (DDS)
Entity type:Individual
Prefix:MR
First Name:MAURICE
Middle Name:GEORGE
Last Name:THEBERGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BERKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01830
Mailing Address - Country:US
Mailing Address - Phone:978-374-4062
Mailing Address - Fax:
Practice Address - Street 1:50 PROSPECT STREET
Practice Address - Street 2:SUITE 402
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841
Practice Address - Country:US
Practice Address - Phone:978-686-0421
Practice Address - Fax:978-686-8246
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA94371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0237396Medicare ID - Type Unspecified