Provider Demographics
NPI:1215929286
Name:BERGEN, MICHELE SHOSHANA (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:SHOSHANA
Last Name:BERGEN
Suffix:
Gender:F
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-4501
Mailing Address - Country:US
Mailing Address - Phone:203-661-4231
Mailing Address - Fax:203-661-0155
Practice Address - Street 1:49 LAKE AVE
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-4501
Practice Address - Country:US
Practice Address - Phone:203-661-4231
Practice Address - Fax:203-661-0155
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0092751223S0112X
CT042206204E00000X
NY0501811223S0112X
NY231685204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001422063Medicaid
CT850000013Medicare ID - Type Unspecified
CTI23887Medicare UPIN