Provider Demographics
NPI:1629527791
Name:MARQUARDT, HEATHER SUE (RDH)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:SUE
Last Name:MARQUARDT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 SAMANTHA ST
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-8030
Mailing Address - Country:US
Mailing Address - Phone:920-562-2714
Mailing Address - Fax:
Practice Address - Street 1:2214 SAMANTHA ST
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-8030
Practice Address - Country:US
Practice Address - Phone:920-562-2714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11097124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist