=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922029891
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZACKARY DREW BERGESON DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2006
-----------------------------------------------------
Last Update Date | 03/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 S PEORIA ST
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80012-3464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-367-2273
-----------------------------------------------------
Fax | 303-367-5385
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22959 E SMOKY HILL RD APT A206
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80015-6702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-439-4307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 19482
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 9128
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------