Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 9066 | MN |
NPI | 1073635926 |
---|---|
Provider Name | Dr. Michelle Louise Bergsrud |
First Address | Minnetonka, MN 55343-9442 |
Second Address | Minnetonka, MN 55343-9442 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2007 |
Last Update Date | 08/07/2007 |