Provider Demographics
NPI:1598063885
Name:R.A. BERQUIST, D.D.S., P.C.
Entity Type:Organization
Organization Name:R.A. BERQUIST, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BERQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-799-4488
Mailing Address - Street 1:19710 GOVERNORS HWY
Mailing Address - Street 2:SUITE #4
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2080
Mailing Address - Country:US
Mailing Address - Phone:708-799-4488
Mailing Address - Fax:708-799-7956
Practice Address - Street 1:19710 GOVERNORS HWY
Practice Address - Street 2:SUITE #4
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2080
Practice Address - Country:US
Practice Address - Phone:708-799-4488
Practice Address - Fax:708-799-7956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-0119291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty