Provider Demographics
NPI:1154914216
Name:BERGERON, KELSEY ANN
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANN
Last Name:BERGERON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 NIAGARA FALLS BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-7531
Mailing Address - Country:US
Mailing Address - Phone:716-831-2277
Mailing Address - Fax:
Practice Address - Street 1:1730 NIAGARA FALLS BLVD STE 300
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-7531
Practice Address - Country:US
Practice Address - Phone:716-831-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY062750122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program