Provider Demographics
NPI:1548539125
Name:BERG, STEPHEN CHARLES (DMD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CHARLES
Last Name:BERG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2133 PEPPERRELL ST
Mailing Address - Street 2:BUILDING 3352
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5313
Mailing Address - Country:US
Mailing Address - Phone:210-292-6258
Mailing Address - Fax:210-292-2618
Practice Address - Street 1:374 MEDICAL GROUP
Practice Address - Street 2:UNIT 5224
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96328-5224
Practice Address - Country:US
Practice Address - Phone:315-225-3671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX275121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice