MEDICARE: ROBERT T. BERGMAN, DDS, MS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	D21237	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B21237-01	OTHER	CA	MED-CAL PROVIDER

General Provider Information

NPI Number	:	1205011293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBERT T. BERGMAN, DDS, MS, INC.

Provider Business Mailing Address
First Line	:	400 MOBIL AVE
Second Line	:	C-1
City	:	CAMARILLO
State	:	CA
Zip	:	93010-6338
Country	:	US
Telephone Number	:	805-482-7284
Fax Number	:	805-482-5196

Provider Business Practice Location Address
First Line	:	400 MOBIL AVE
Second Line	:	C-1
City	:	CAMARILLO
State	:	CA
Zip	:	93010-6338
Country	:	US
Telephone Number	:	805-482-7284
Fax Number	:	805-482-5196

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. ROBERT T BERGMAN
Credential	:	D.D.S.
Telephone Number	:	805-482-7284

Provider Enumeration Date	:	01/08/2008
Last Update Date	:	01/08/2008

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