Provider Demographics
NPI:1184710766
Name:BERGERON, HAL DOUGLAS (DMD)
Entity type:Individual
Prefix:DR
First Name:HAL
Middle Name:DOUGLAS
Last Name:BERGERON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:CLINTON
Other - Middle Name:CENTER
Other - Last Name:DENTAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:23 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08809-1253
Mailing Address - Country:US
Mailing Address - Phone:908-730-7565
Mailing Address - Fax:908-730-7965
Practice Address - Street 1:23 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NJ
Practice Address - Zip Code:08809-1253
Practice Address - Country:US
Practice Address - Phone:908-730-7565
Practice Address - Fax:908-730-7965
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ16945122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist