Provider Demographics
NPI:1922029891
Name:BERGESON, ZACKARY DREW (DMD)
Entity Type:Individual
Prefix:
First Name:ZACKARY
Middle Name:DREW
Last Name:BERGESON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22959 E SMOKY HILL RD
Mailing Address - Street 2:APT A206
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-6702
Mailing Address - Country:US
Mailing Address - Phone:215-439-4307
Mailing Address - Fax:
Practice Address - Street 1:1050 S PEORIA ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-3464
Practice Address - Country:US
Practice Address - Phone:303-367-2273
Practice Address - Fax:303-367-5385
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT19482122300000X
CO91281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09177353Medicaid