Provider Demographics
NPI:1003915174
Name:BERGSTROM, JENNIFER E (DDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:E
Other - Last Name:MODAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:413 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-2703
Mailing Address - Country:US
Mailing Address - Phone:608-251-8790
Mailing Address - Fax:608-251-0242
Practice Address - Street 1:413 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2703
Practice Address - Country:US
Practice Address - Phone:608-251-8790
Practice Address - Fax:608-251-0242
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice