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General NPI Number Information
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NPI Number | 1487760054
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Entity Type | Organization
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Legal Business Name | BRYAN M BERGENS DDS PA
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Dates
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Enumeration Date | 08/23/2006
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Last Update Date | 05/21/2013
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Provider Practice Location Address
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Address Line | 724 SOUTH BEACH STREET SUITE 4
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City | DAYTONA BEACH
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State | FL
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Zip | 32114
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Country | US
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Telephone | 386-258-2213
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Fax | 386-253-7943
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Provider Business Mailing Address
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Address Line | 724 SOUTH BEACH STREET SUITE 4
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City | DAYTONA BEACH
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State | FL
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Zip | 32114
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Country | US
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Telephone | 386-258-2213
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Fax | 386-253-7943
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Authorized Official
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Title or Position | CEO
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Name | MRS. BRIDGET ROWBATHAM BERGENS
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Credential |
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Telephone | 386-258-2213
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN13806
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License Number State | FL
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