Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 36658 | TX |
NPI | 1225792906 |
---|---|
Provider Name | Dr. Clara Bergeron |
First Address | Dallas, TX 75243-6425 |
Second Address | Dallas, TX 75254-9196 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/10/2021 |
Last Update Date | 28/10/2021 |