Provider Demographics
NPI:1194035865
Name:BERGQUAM, ERIC P (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:P
Last Name:BERGQUAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 DEBORAH RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132
Mailing Address - Country:US
Mailing Address - Phone:503-538-5476
Mailing Address - Fax:503-538-8293
Practice Address - Street 1:906 DEBORAH RD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132
Practice Address - Country:US
Practice Address - Phone:503-538-5476
Practice Address - Fax:503-538-8293
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD83101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice