Provider Demographics
NPI:1003876921
Name:BERGIN, DENNIS G (OD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:G
Last Name:BERGIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:DENNIS
Other - Middle Name:
Other - Last Name:BERGIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:228 JULIA LYNN LANE
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-8184
Mailing Address - Country:US
Mailing Address - Phone:770-424-5367
Mailing Address - Fax:678-337-7933
Practice Address - Street 1:400 BARRETT PKWY STE 500
Practice Address - Street 2:SEARS OPTICAL-TOWN CENTER MALL
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4997
Practice Address - Country:US
Practice Address - Phone:770-424-5367
Practice Address - Fax:678-337-7933
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA-1071-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA843143605AMedicaid
GAU-17568Medicare UPIN
GA41ZCBQZMedicare ID - Type Unspecified