Healthcare Provider Details

I. General information

NPI: 1063994333
Provider Name (Legal Business Name): REGINA GELMAN-BERCOVICH DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7520 NW 104TH AVE UNIT A105
DORAL FL
33178-3375
US

IV. Provider business mailing address

1546 BREAKWATER TER
HOLLYWOOD FL
33019-5023
US

V. Phone/Fax

Practice location:
  • Phone: 786-408-0177
  • Fax:
Mailing address:
  • Phone: 617-817-0709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN19630
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: