Healthcare Provider Details

I. General information

NPI: 1689927386
Provider Name (Legal Business Name): STACI BERGERON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 BARRANCA PKWY STE 100
IRVINE CA
92604-4754
US

IV. Provider business mailing address

4330 BARRANCA PKWY STE 100
IRVINE CA
92604-4754
US

V. Phone/Fax

Practice location:
  • Phone: 909-489-0100
  • Fax:
Mailing address:
  • Phone: 909-489-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number21911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: