Provider Demographics
NPI:1497811301
Name:BERGMAN, ROBERT TODD (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:TODD
Last Name:BERGMAN
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 1:2350 NORTHPARK
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203
Mailing Address - Country:US
Mailing Address - Phone:812-372-7312
Mailing Address - Fax:812-378-9451
Practice Address - Street 1:2350 NORTHPARK
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203
Practice Address - Country:US
Practice Address - Phone:812-372-7312
Practice Address - Fax:812-378-9451
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120092161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000251000OtherBCBS
IN052940CMedicare PIN
IN000000251000OtherBCBS