Provider Demographics
NPI:1275612376
Name:BERGERON, RANDALL AUGUST (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:AUGUST
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 1:7930 WRENWOOD BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-7700
Mailing Address - Country:US
Mailing Address - Phone:225-924-3635
Mailing Address - Fax:225-924-3736
Practice Address - Street 1:7930 WRENWOOD BLVD
Practice Address - Street 2:STE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-7700
Practice Address - Country:US
Practice Address - Phone:225-924-3635
Practice Address - Fax:225-924-3736
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA38091223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1838098Medicaid