Provider Demographics
NPI:1346339595
Name:YOUNGQUIST KENNEDY ORTHODONTICS, LTD.
Entity Type:Organization
Organization Name:YOUNGQUIST KENNEDY ORTHODONTICS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:R
Authorized Official - Last Name:YOUNGQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-248-0101
Mailing Address - Street 1:255 HAVENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-1917
Mailing Address - Country:US
Mailing Address - Phone:262-248-0101
Mailing Address - Fax:262-248-2941
Practice Address - Street 1:255 HAVENWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-1917
Practice Address - Country:US
Practice Address - Phone:262-248-0101
Practice Address - Fax:262-248-2941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2191B1223X0400X
WI6951-151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33395900Medicaid