Provider Demographics
NPI:1134747157
Name:DERGAN, TESSA MCDERMOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:TESSA
Middle Name:MCDERMOTT
Last Name:DERGAN
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 1:9222 BURT ST APT 310
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-2431
Mailing Address - Country:US
Mailing Address - Phone:402-320-1027
Mailing Address - Fax:
Practice Address - Street 1:5311 S 138TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2913
Practice Address - Country:US
Practice Address - Phone:402-334-5656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE76511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice