Provider Demographics
NPI:1750475729
Name:BERGERON, COREY M (DDS)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:M
Last Name:BERGERON
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 1:636 S BELLE CIR
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-4635
Mailing Address - Country:US
Mailing Address - Phone:337-332-5141
Mailing Address - Fax:337-332-5131
Practice Address - Street 1:636 S BELLE CIR
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-4635
Practice Address - Country:US
Practice Address - Phone:337-332-5141
Practice Address - Fax:337-332-5131
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA53081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice