Provider Demographics
NPI:1528256922
Name:VAN BERGEN, MICHEL LAURENTIUS (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHEL
Middle Name:LAURENTIUS
Last Name:VAN BERGEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:450 SUTTER ST
Mailing Address - Street 2:SUITE 1932
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94108-4206
Mailing Address - Country:US
Mailing Address - Phone:415-986-7655
Mailing Address - Fax:415-986-6967
Practice Address - Street 1:450 SUTTER ST
Practice Address - Street 2:SUITE 1932
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94108-4206
Practice Address - Country:US
Practice Address - Phone:415-986-7655
Practice Address - Fax:415-986-6967
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA308741223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics