Provider Demographics
NPI:1134245830
Name:JACK-BERGLUND, RACHEL EMILY (DDS)
Entity type:Individual
Prefix:DR
First Name:RACHEL
Middle Name:EMILY
Last Name:JACK-BERGLUND
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1698 E MENLO AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-4306
Mailing Address - Country:US
Mailing Address - Phone:559-349-6218
Mailing Address - Fax:
Practice Address - Street 1:4747 N. FIRST ST
Practice Address - Street 2:SUITE 113
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726
Practice Address - Country:US
Practice Address - Phone:559-225-4540
Practice Address - Fax:559-225-0364
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55316122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist