=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093744674
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVEN BERGMAN, DMD & CLARK INGOLDSBY, DDS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 FORBES RD SUITE 230
-----------------------------------------------------
City | BRAINTREE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02184-2605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-843-7905
-----------------------------------------------------
Fax | 781-356-2388
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 FORBES RD SUITE 230
-----------------------------------------------------
City | BRAINTREE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02184-2605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-843-7905
-----------------------------------------------------
Fax | 781-356-2388
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DENTIST
-----------------------------------------------------
Name | DR. STEVE W BERGMAN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 781-843-7905
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 15349
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 18388
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------