Provider Demographics
NPI:1639800808
Name:BERGERON, SAMANTHA YEVGENYEVNA (DDS)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:YEVGENYEVNA
Last Name:BERGERON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11212 MORNING CREEK DR S
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-4050
Mailing Address - Country:US
Mailing Address - Phone:910-232-8503
Mailing Address - Fax:
Practice Address - Street 1:4142 ADAMS AVE STE 104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-2594
Practice Address - Country:US
Practice Address - Phone:619-326-0157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109297122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist