Provider Demographics
NPI:1043330152
Name:IRVINE PEDIATRIC DENTISTRY & ORTHODONTICS
Entity Type:Organization
Organization Name:IRVINE PEDIATRIC DENTISTRY & ORTHODONTICS
Other - Org Name:IPDO
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BERGEMAN
Authorized Official - Last Name:HAAG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-559-0674
Mailing Address - Street 1:4902 IRVINE CENTER DR
Mailing Address - Street 2:SUITE 111
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3305
Mailing Address - Country:US
Mailing Address - Phone:949-559-0674
Mailing Address - Fax:949-559-7909
Practice Address - Street 1:4902 IRVINE CENTER DR
Practice Address - Street 2:SUITE 111
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-3305
Practice Address - Country:US
Practice Address - Phone:949-559-0674
Practice Address - Fax:949-559-7909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA156731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty