Provider Demographics
NPI:1174780274
Name:BERGER, VITALIY JACOB (DDS)
Entity type:Individual
Prefix:DR
First Name:VITALIY
Middle Name:JACOB
Last Name:BERGER
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 1:180 OTAY LAKES RD
Mailing Address - Street 2:204
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-2443
Mailing Address - Country:US
Mailing Address - Phone:619-479-2111
Mailing Address - Fax:
Practice Address - Street 1:180 OTAY LAKES RD
Practice Address - Street 2:204
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-2443
Practice Address - Country:US
Practice Address - Phone:619-479-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-18
Last Update Date:2008-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA513211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice