Provider Demographics
NPI:1194013094
Name:BERGAN, ALESIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALESIA
Middle Name:
Last Name:BERGAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5907 FENWICK AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-2407
Mailing Address - Country:US
Mailing Address - Phone:410-428-1201
Mailing Address - Fax:
Practice Address - Street 1:15200 SHADY GROVE RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3218
Practice Address - Country:US
Practice Address - Phone:301-926-4408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD149631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice