Healthcare Provider Details

I. General information

NPI: 1265920086
Provider Name (Legal Business Name): MARISSA BERGTHOLD DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7701 W 119TH ST
OVERLAND PARK KS
66213-1103
US

IV. Provider business mailing address

7701 W 119TH ST
OVERLAND PARK KS
66213-1103
US

V. Phone/Fax

Practice location:
  • Phone: 913-529-5999
  • Fax: 913-529-5995
Mailing address:
  • Phone: 913-529-5999
  • Fax: 913-529-5995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number62193
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2024026317
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: