Healthcare Provider Details

I. General information

NPI: 1962726950
Provider Name (Legal Business Name): IZU & BERGMANN DENTAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74303 HIGHWAY 111 SUITE 2A
PALM DESERT CA
92260-4141
US

IV. Provider business mailing address

74303 HIGHWAY 111 SUITE 2A
PALM DESERT CA
92260-4141
US

V. Phone/Fax

Practice location:
  • Phone: 760-340-0888
  • Fax: 760-340-6827
Mailing address:
  • Phone: 760-340-0888
  • Fax: 760-340-6827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number033244
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number33245
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number33245
License Number StatePA

VIII. Authorized Official

Name: MRS. TERRI SAWDEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 760-340-0888