Provider Demographics
NPI:1912950791
Name:BERTAGNA, DAVID EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EDWARD
Last Name:BERTAGNA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-1832
Mailing Address - Country:US
Mailing Address - Phone:773-736-1406
Mailing Address - Fax:773-736-1487
Practice Address - Street 1:4020 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-1832
Practice Address - Country:US
Practice Address - Phone:773-736-1406
Practice Address - Fax:773-736-1487
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist