Provider Demographics
NPI:1922490333
Name:BERGANSKE, SHELLEY DANIELLE WADE (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:DANIELLE WADE
Last Name:BERGANSKE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:#150
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024
Mailing Address - Country:US
Mailing Address - Phone:770-614-8914
Mailing Address - Fax:
Practice Address - Street 1:1380 PEACHTREE INDUSTRIAL BLVD STE 150
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-3795
Practice Address - Country:US
Practice Address - Phone:770-614-8914
Practice Address - Fax:770-614-8917
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014966390200000X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty