Provider Demographics
NPI:1386618643
Name:BERGEY, DAVID ALAN (DDS01)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALAN
Last Name:BERGEY
Suffix:
Gender:M
Credentials:DDS01
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 3RD AVE
Mailing Address - Street 2:SUITE#1
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5806
Mailing Address - Country:US
Mailing Address - Phone:570-288-9070
Mailing Address - Fax:570-288-4201
Practice Address - Street 1:550 3RD AVE
Practice Address - Street 2:SUITE#1
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5806
Practice Address - Country:US
Practice Address - Phone:570-288-9070
Practice Address - Fax:570-288-4201
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025437L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA407114OtherBLUE SHIELD MEDICAL
PA077001OtherFIRST PRIORITY HEALTH
PA407114OtherBLUE SHIELD MEDICAL
PA407114JG5Medicare ID - Type Unspecified