Provider Demographics
NPI:1447365853
Name:BERGER, SHANE TERRYL (D D S)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:TERRYL
Last Name:BERGER
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N ELM ST STE A
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76201-6905
Mailing Address - Country:US
Mailing Address - Phone:940-566-1828
Mailing Address - Fax:940-566-3915
Practice Address - Street 1:1010 N ELM ST STE A
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76201-6905
Practice Address - Country:US
Practice Address - Phone:940-566-1828
Practice Address - Fax:940-566-3915
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX193531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD19353OtherBCBS TX PROVIDER ID #
TX19353OtherLICENSE NUMBER