Provider Demographics
NPI:1417701400
Name:CRONQUIST, KELTON (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:KELTON
Middle Name:
Last Name:CRONQUIST
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 N TULLSHIRE WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-3305
Mailing Address - Country:US
Mailing Address - Phone:435-760-0323
Mailing Address - Fax:
Practice Address - Street 1:1200 W CHERRY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4930
Practice Address - Country:US
Practice Address - Phone:208-898-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-56051223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics