Provider Demographics
NPI:1942646617
Name:BERGENS, BRYAN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:MICHAEL
Last Name:BERGENS
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 1:724 S BEACH ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5441
Mailing Address - Country:US
Mailing Address - Phone:386-258-2213
Mailing Address - Fax:386-253-7943
Practice Address - Street 1:724 S BEACH ST
Practice Address - Street 2:SUITE 4
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5441
Practice Address - Country:US
Practice Address - Phone:386-258-2213
Practice Address - Fax:386-253-7943
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN138061223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1487760054OtherNPI