Provider Demographics
NPI:1720001449
Name:HALLQUIST, THOMAS (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:HALLQUIST
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 1:2163 W 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-8043
Mailing Address - Country:US
Mailing Address - Phone:920-235-6070
Mailing Address - Fax:920-235-5668
Practice Address - Street 1:2163 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-8043
Practice Address - Country:US
Practice Address - Phone:920-235-6070
Practice Address - Fax:920-235-5668
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2675-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33424200Medicaid