Provider Demographics
NPI:1407907595
Name:BERGHORST, JAMES L (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:L
Last Name:BERGHORST
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 1:596 BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9756
Mailing Address - Country:US
Mailing Address - Phone:616-457-0450
Mailing Address - Fax:616-457-3199
Practice Address - Street 1:596 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-9756
Practice Address - Country:US
Practice Address - Phone:616-457-0450
Practice Address - Fax:616-457-3199
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI115291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice