Provider Demographics
NPI:1790256428
Name:HALLQUIST DENTAL, LLC
Entity Type:Organization
Organization Name:HALLQUIST DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-235-6070
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental