Provider Demographics
NPI:1083789804
Name:BERGERON, DANIEL MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MICHAEL
Last Name:BERGERON
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 1:3112 AIRPORT WAY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4754
Mailing Address - Country:US
Mailing Address - Phone:907-456-5600
Mailing Address - Fax:907-451-6470
Practice Address - Street 1:3112 AIRPORT WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4754
Practice Address - Country:US
Practice Address - Phone:907-456-5600
Practice Address - Fax:907-451-6470
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK8191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK822825OtherTRICARE
AKDD0819Medicaid