Provider Demographics
NPI:1366642449
Name:ELMQUIST, ERIC M (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:M
Last Name:ELMQUIST
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 1:2222 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3709
Mailing Address - Country:US
Mailing Address - Phone:715-395-5393
Mailing Address - Fax:715-392-1935
Practice Address - Street 1:2222 E 5TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-3709
Practice Address - Country:US
Practice Address - Phone:715-394-5411
Practice Address - Fax:715-392-5086
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND115451223G0001X
WI60891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6089OtherWISCONSIN LICENSE
MND11545OtherMINNESOTA LICENSE