Provider Demographics
NPI:1386465193
Name:BERGREN, ALEXANDRA NICOLE (DMD)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:BERGREN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ALEXANDRA
Other - Middle Name:NICOLE
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:749 LINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3323
Mailing Address - Country:US
Mailing Address - Phone:445-202-9521
Mailing Address - Fax:
Practice Address - Street 1:1740 ROBERT ST S STE 110
Practice Address - Street 2:
Practice Address - City:WEST SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3771
Practice Address - Country:US
Practice Address - Phone:651-347-1252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND15203122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty