Healthcare Provider Details

I. General information

NPI: 1508867599
Provider Name (Legal Business Name): STEWART ALAN BERGMAN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W BALTIMORE ST SUITE 414
BALTIMORE MD
21201-1510
US

IV. Provider business mailing address

650 W BALTIMORE ST SUITE 414
BALTIMORE MD
21201-1510
US

V. Phone/Fax

Practice location:
  • Phone: 410-706-6195
  • Fax:
Mailing address:
  • Phone: 410-706-6195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5840
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: