Provider Demographics
NPI:1679640312
Name:AHNQUIST, MARY SUZANNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:SUZANNE
Last Name:AHNQUIST
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:M.
Other - Middle Name:SUZANNE
Other - Last Name:AHNQUIST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1225 CORNELL AVE
Mailing Address - Street 2:
Mailing Address - City:DREXEL HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19026-3219
Mailing Address - Country:US
Mailing Address - Phone:859-333-8757
Mailing Address - Fax:
Practice Address - Street 1:1225 CORNELL AVE
Practice Address - Street 2:
Practice Address - City:DREXEL HILL
Practice Address - State:PA
Practice Address - Zip Code:19026-3219
Practice Address - Country:US
Practice Address - Phone:859-333-8757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6029122300000X
PADS039280122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist