Provider Demographics
NPI:1477883270
Name:SODERQUIST, SCOTT A (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
Last Name:SODERQUIST
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 1:1118 N LARKIN AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-3456
Mailing Address - Country:US
Mailing Address - Phone:815-725-4070
Mailing Address - Fax:815-725-4054
Practice Address - Street 1:1118 N LARKIN AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-3456
Practice Address - Country:US
Practice Address - Phone:815-725-4070
Practice Address - Fax:815-725-4054
Is Sole Proprietor?:No
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210021121223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics