Provider Demographics
NPI:1356359772
Name:BERGMAN, DENNIS WILBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:WILBERT
Last Name:BERGMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13632 CANADA DEL OSO PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-8030
Mailing Address - Country:US
Mailing Address - Phone:505-298-6684
Mailing Address - Fax:
Practice Address - Street 1:4041 BARBARA LOOP SE
Practice Address - Street 2:SUITE A
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1065
Practice Address - Country:US
Practice Address - Phone:505-891-1500
Practice Address - Fax:505-891-8400
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD-1948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0003299Medicaid
NM1465519OtherUNITED CONCORDIA DENTAL
NMP7216Medicaid
NMNM01810FOtherBLUE CROSS/BLUE SHIELD