Provider Demographics
NPI:1427281096
Name:BERGEVIN, ZACHARY (DDS)
Entity type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:
Last Name:BERGEVIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 818
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-0818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2021 SE SEDGWICK RD
Practice Address - Street 2:SUITE #3
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-9502
Practice Address - Country:US
Practice Address - Phone:253-592-3568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE 60105851122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist