Marissa Bergthold, DDS

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

62193 Issued in KS

Practice address

7701 W 119TH St
Overland Park, KS 66213-1103

Phone

(913) 529-5999

Fax

(913) 529-5995

NPI assigned

Apr 26, 2018

Last updated

Jul 11, 2024By the provider in NPPES

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Opted out of Medicare

Yes, effective Aug 3, 2023 through Aug 3, 2027

Medicare enrollment (NPD)

Enrolled

State licenses

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

{
    "created_epoch": "1524700800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1720656000000",
    "number": "1265920086",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7701 W 119TH ST",
            "city": "OVERLAND PARK",
            "state": "KS",
            "postal_code": "662131103",
            "telephone_number": "913-529-5999",
            "fax_number": "913-529-5995"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "7701 W 119TH ST",
            "city": "OVERLAND PARK",
            "state": "KS",
            "postal_code": "662131103",
            "telephone_number": "913-529-5999",
            "fax_number": "913-529-5995"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "19045 E Valley View Pkwy Ste H",
            "address_purpose": "LOCATION",
            "city": "Independence",
            "state": "MO",
            "postal_code": "640559942",
            "country_code": "US",
            "telephone_number": "913-529-5999",
            "fax_number": "913-529-5995",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BERGTHOLD",
        "first_name": "MARISSA",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2018-04-26",
        "last_updated": "2024-07-11",
        "certification_date": "2024-07-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "KS",
            "license": "62193",
            "primary": true
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "MO",
            "license": "2024026317",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Lisa Ann Bergeson, SLP
• Allyson Bergman
• Jamie Lynn Bergman, LMSW
• Bergner Chiropractic, LLC
• Luke Edward Bergner, DC
• Sarah Berke
• Celina C Bernabe, DO
• Bernard J Sullivan PHD LLC
• Jennifer P Bernard, M.D.
• John R Bernard, M.D.

• Oral and Maxillofacial Surgery (Dentist) in Overland Park, KS
• Providers in Overland Park, KS by specialty
• Oral and Maxillofacial Surgery (Dentist) in Kansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 11, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.