Provider Demographics
NPI:1205011293
Name:ROBERT T. BERGMAN, DDS, MS, INC.
Entity Type:Organization
Organization Name:ROBERT T. BERGMAN, DDS, MS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:805-482-7284
Mailing Address - Street 1:400 MOBIL AVE
Mailing Address - Street 2:C-1
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-6338
Mailing Address - Country:US
Mailing Address - Phone:805-482-7284
Mailing Address - Fax:805-482-5196
Practice Address - Street 1:400 MOBIL AVE
Practice Address - Street 2:C-1
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6338
Practice Address - Country:US
Practice Address - Phone:805-482-7284
Practice Address - Fax:805-482-5196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD21237261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB21237-01OtherMED-CAL PROVIDER