Healthcare Provider Details

I. General information

NPI: 1356980882
Provider Name (Legal Business Name): KAYLEE ANNE BERGMAN DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLEE ANNE COCKE

II. Dates (important events)

Enumeration Date: 01/01/2020
Last Update Date: 01/01/2020
Certification Date: 01/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6804 SILVERHEEL ST
SHAWNEE KS
66226-5300
US

IV. Provider business mailing address

9613 DEARBORN ST
OVERLAND PARK KS
66207-2823
US

V. Phone/Fax

Practice location:
  • Phone: 913-441-7321
  • Fax:
Mailing address:
  • Phone: 913-708-0860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number61527
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: