Provider Demographics
NPI:1447706205
Name:BERGER, JACOB P (DMD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:P
Last Name:BERGER
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 1:2009 RIVER PARK CT
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7233
Mailing Address - Country:US
Mailing Address - Phone:813-843-9362
Mailing Address - Fax:
Practice Address - Street 1:2215 UNIVERSITY PKWY
Practice Address - Street 2:103
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-7233
Practice Address - Country:US
Practice Address - Phone:941-787-5446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22065122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist