Provider Demographics
NPI:1942224555
Name:SERVAGNO, BERNARD DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:DAVID
Last Name:SERVAGNO
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 1:821 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1179
Mailing Address - Country:US
Mailing Address - Phone:610-882-9910
Mailing Address - Fax:610-882-1747
Practice Address - Street 1:821 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-1179
Practice Address - Country:US
Practice Address - Phone:610-882-9910
Practice Address - Fax:610-882-1747
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025898-L1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA4652440001OtherNAT'L SUPPLIER
PADS025898-LOtherLICENCE NUMBER
PADS025898-LOtherLICENCE NUMBER
PASE612358Medicare ID - Type Unspecified