Provider Demographics
NPI:1376628859
Name:HERGOTT, DAVID KEITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:KEITH
Last Name:HERGOTT
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 1:3 LAURELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2515
Mailing Address - Country:US
Mailing Address - Phone:203-235-3738
Mailing Address - Fax:
Practice Address - Street 1:166 S BROAD ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-6524
Practice Address - Country:US
Practice Address - Phone:203-235-3738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT66801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice