Healthcare Provider Details

I. General information

NPI: 1407239833
Provider Name (Legal Business Name): KATHLEEN ANN BERGMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 SWEDE AVE
TURTLE LAKE WI
54889
US

IV. Provider business mailing address

8540 215TH ST N
FOREST LAKE MN
55025-9114
US

V. Phone/Fax

Practice location:
  • Phone: 715-986-2599
  • Fax:
Mailing address:
  • Phone: 651-341-1521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1001246-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: