Provider Demographics
NPI:1699373829
Name:BERQUIST, DONALD JAY JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:JAY
Last Name:BERQUIST
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:696 LONGFELLOW DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-4817
Mailing Address - Country:US
Mailing Address - Phone:248-672-8903
Mailing Address - Fax:
Practice Address - Street 1:3009 E 92ND ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4598
Practice Address - Country:US
Practice Address - Phone:773-295-2521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-10
Last Update Date:2020-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190326821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice