Provider Demographics
NPI:1093883274
Name:BERGQUIST, CRIAG R (DDS)
Entity Type:Individual
Prefix:DR
First Name:CRIAG
Middle Name:R
Last Name:BERGQUIST
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 1:665 CAMINO DE LOS MARES #204
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673
Mailing Address - Country:US
Mailing Address - Phone:949-661-9680
Mailing Address - Fax:949-661-4872
Practice Address - Street 1:665 CAMINO DE LOS MARES #204
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673
Practice Address - Country:US
Practice Address - Phone:949-661-9680
Practice Address - Fax:949-661-4872
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA299131223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics