Provider Demographics
NPI:1770732943
Name:BERGAN, LATASHIA L (RDH)
Entity type:Individual
Prefix:
First Name:LATASHIA
Middle Name:L
Last Name:BERGAN
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:LATASHIA
Other - Middle Name:L
Other - Last Name:DANIELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:1647 ADMIRAL TAUSSIG BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23511
Mailing Address - Country:US
Mailing Address - Phone:757-953-8547
Mailing Address - Fax:
Practice Address - Street 1:1647 ADMIRAL TAUSSIG BOULEVARD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511
Practice Address - Country:US
Practice Address - Phone:757-953-8547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402203340124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist