Provider Demographics
NPI:1669683025
Name:BERGIEN, TYLER PAUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:PAUL
Last Name:BERGIEN
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 1:945 W BROADWAY
Mailing Address - Street 2:SUITE 201,P O BOX 11779
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001
Mailing Address - Country:US
Mailing Address - Phone:307-734-5200
Mailing Address - Fax:307-733-2922
Practice Address - Street 1:945 W BROADWAY
Practice Address - Street 2:SUITE #201
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-734-5200
Practice Address - Fax:307-733-2922
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY#10041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice