NPIMap

Individual provider Active NPI

Michele Shoshana Bergen, D.M.D., M.D.

  • Oral and Maxillofacial Surgery (Dentist)
  • Greenwich, CT
National Provider Identifier
1215929286
Registry record updated Aug 8, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X
License
009275 Issued in CT
Practice address
49 Lake Ave
Greenwich, CT 06830-4501
Phone
(203) 661-4231
Fax
(203) 661-0155
NPI assigned
Aug 16, 2005
Last updated
Aug 8, 2012By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 8, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Oral and Maxillofacial Surgery (Dentist) 1223S0112X 009275 CT Primary
Oral & Maxillofacial Surgery (D.M.D.) 204E00000X 042206 CT
Oral and Maxillofacial Surgery (Dentist) 1223S0112X 050181 NY
Oral & Maxillofacial Surgery (D.M.D.) 204E00000X 231685 NY

Addresses

Primary practice location

49 Lake Ave
Greenwich, CT 06830-4501

Mailing address

49 Lake Ave
Greenwich, CT 06830-4501
Phone (203) 661-4231

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CT
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20050120000772 CT Practitioner - Maxillofacial Surgery 4880643436 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Maxillofacial Surgery
Education
Rutgers New Jersey Medical School, 2001
Medicare assignment
Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

49 Lake Ave
Suite LL4
Greenwich, CT 06830-4501
Phone (203) 661-4231

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of tissue1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
009275CTMDOral and Maxillofacial Surgery (Dentist)
050181NYMDOral and Maxillofacial Surgery (Dentist)
042206CTMDOral & Maxillofacial Surgery (D.M.D.)
231685NYMDOral & Maxillofacial Surgery (D.M.D.)

Practice roles

OrganizationSpecialtyStatusNew patients
Center for Oral and Implant Surgery of Greenwich, LLC CurrentSince Jan 1, 2010 Accepting new patients
Raymond Sekiguchi M.D., P.C. PastSince Jan 1, 2010 Accepting new patients

Locations

49 Lake Ave
Greenwich, CT 06830
Phone (203) 661-9383

49 Lake Ave
Ste LL4
Greenwich, CT 06830
Phone (203) 661-4231

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 26

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 26

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1124150400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1344384000000",
    "number": "1215929286",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "49 LAKE AVE",
            "city": "GREENWICH",
            "state": "CT",
            "postal_code": "068304501",
            "telephone_number": "203-661-4231",
            "fax_number": "203-661-0155"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "49 LAKE AVE",
            "city": "GREENWICH",
            "state": "CT",
            "postal_code": "068304501",
            "telephone_number": "203-661-4231",
            "fax_number": "203-661-0155"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BERGEN",
        "first_name": "MICHELE",
        "middle_name": "SHOSHANA",
        "name_prefix": "Dr.",
        "credential": "D.M.D., M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2005-08-16",
        "last_updated": "2012-08-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "CT",
            "license": "009275",
            "primary": true
        },
        {
            "code": "204E00000X",
            "taxonomy_group": "",
            "desc": "Oral & Maxillofacial Surgery",
            "state": "CT",
            "license": "042206",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NY",
            "license": "050181",
            "primary": false
        },
        {
            "code": "204E00000X",
            "taxonomy_group": "",
            "desc": "Oral & Maxillofacial Surgery",
            "state": "NY",
            "license": "231685",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Greenwich, CT

Sources for this page

Verify at the official NPI Registry.