Provider Demographics
NPI:1386277507
Name:BERGSTROM, JENNIFER WILLIAMS (DDS, MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WILLIAMS
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6121 N BAY RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH BAY
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4326
Mailing Address - Country:US
Mailing Address - Phone:916-475-4401
Mailing Address - Fax:
Practice Address - Street 1:5000 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53295-3098
Practice Address - Country:US
Practice Address - Phone:414-384-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2025-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10925122300000X
WI8426620204E00000X
WI6001751151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1386277507Medicaid