Provider Demographics
NPI:1801062823
Name:BERGESON, PETER A (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:A
Last Name:BERGESON
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 1:1680 CHAMBERS ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-3655
Mailing Address - Country:US
Mailing Address - Phone:541-345-2042
Mailing Address - Fax:541-345-4012
Practice Address - Street 1:1680 CHAMBERS ST
Practice Address - Street 2:SUITE 204
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3655
Practice Address - Country:US
Practice Address - Phone:541-345-2042
Practice Address - Fax:541-345-4012
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT361779-9922122300000X
ORD90401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist