Healthcare Provider Details

I. General information

NPI: 1386277507
Provider Name (Legal Business Name): JENNIFER WILLIAMS BERGSTROM DDS, MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 08/03/2025
Certification Date: 08/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W NATIONAL AVE
MILWAUKEE WI
53295-3098
US

IV. Provider business mailing address

6121 N BAY RIDGE AVE
WHITEFISH BAY WI
53217-4326
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-2000
  • Fax:
Mailing address:
  • Phone: 916-475-4401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD10925
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number8426620
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number600175115
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: