Provider Demographics
NPI:1407931512
Name:BERGMANN, CAROLYN IZU (DMD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:IZU
Last Name:BERGMANN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:IZU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:74303 HIGHWAY 111
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-4141
Mailing Address - Country:US
Mailing Address - Phone:760-340-0888
Mailing Address - Fax:760-340-6827
Practice Address - Street 1:74303 HIGHWAY 111
Practice Address - Street 2:SUITE 2A
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-4141
Practice Address - Country:US
Practice Address - Phone:760-340-0888
Practice Address - Fax:760-340-6827
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0332441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice