Provider Demographics
NPI:1780847129
Name:BERGGREN, TODD J (DDS)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:J
Last Name:BERGGREN
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 1:15421 MAIN ST
Mailing Address - Street 2:STE 101
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-9002
Mailing Address - Country:US
Mailing Address - Phone:425-316-8095
Mailing Address - Fax:425-316-9210
Practice Address - Street 1:15421 MAIN ST
Practice Address - Street 2:STE 101
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-9002
Practice Address - Country:US
Practice Address - Phone:425-316-8095
Practice Address - Fax:425-316-9210
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000111901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice