Provider Demographics
NPI:1619270337
Name:BERGMAN FAMILY DENTAL
Entity Type:Organization
Organization Name:BERGMAN FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:636-391-9666
Mailing Address - Street 1:15421 CLAYTON RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3161
Mailing Address - Country:US
Mailing Address - Phone:636-391-9666
Mailing Address - Fax:
Practice Address - Street 1:15421 CLAYTON RD
Practice Address - Street 2:SUITE 302
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-3161
Practice Address - Country:US
Practice Address - Phone:636-391-9666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005018472122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty