Provider Demographics
NPI:1780763755
Name:ERIC P BERGQUAM DMD PC
Entity type:Organization
Organization Name:ERIC P BERGQUAM DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:P
Authorized Official - Last Name:BERGQUAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-538-5476
Mailing Address - Street 1:906 DEBORAH RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132
Mailing Address - Country:US
Mailing Address - Phone:503-538-5476
Mailing Address - Fax:503-538-8293
Practice Address - Street 1:906 DEBORAH RD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132
Practice Address - Country:US
Practice Address - Phone:503-538-5476
Practice Address - Fax:503-538-8293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD83101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty