Provider Demographics
NPI:1417064312
Name:BERGMAN DDS PS
Entity Type:Organization
Organization Name:BERGMAN DDS PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-693-9349
Mailing Address - Street 1:701 OFFICERS ROW
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661
Mailing Address - Country:US
Mailing Address - Phone:360-693-9349
Mailing Address - Fax:360-695-2673
Practice Address - Street 1:701 OFFICERS ROW
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661
Practice Address - Country:US
Practice Address - Phone:360-693-9349
Practice Address - Fax:360-695-2673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA8362122300000X
WA8550122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty