Provider Demographics
NPI:1962757674
Name:BERGERON, STEFAN PAUL (DDS)
Entity type:Individual
Prefix:
First Name:STEFAN
Middle Name:PAUL
Last Name:BERGERON
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 1:976 OLD SQUAW PASS RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-4737
Mailing Address - Country:US
Mailing Address - Phone:847-648-0082
Mailing Address - Fax:
Practice Address - Street 1:2902 EVERGREEN PKWY
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-7916
Practice Address - Country:US
Practice Address - Phone:303-674-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO202826122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist