Provider Demographics
NPI:1982057550
Name:BERGREN, JOSEPHINE
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:
Last Name:BERGREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618TH DENTAL CO (AS)
Mailing Address - Street 2:UNIT 15652
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96205-5652
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BOX 81 618TH DENTAL CO. (AS)
Practice Address - Street 2:UNIT 15652
Practice Address - City:APO AP
Practice Address - State:CA
Practice Address - Zip Code:96205-5652
Practice Address - Country:US
Practice Address - Phone:010-394-1653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant