Provider Demographics
NPI:1972675288
Name:DAHLQUIST, CARLYLE HOLBROOK (DDS)
Entity Type:Individual
Prefix:
First Name:CARLYLE
Middle Name:HOLBROOK
Last Name:DAHLQUIST
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 1:1508 NW MOCK AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-3095
Mailing Address - Country:US
Mailing Address - Phone:816-228-7176
Mailing Address - Fax:816-224-9555
Practice Address - Street 1:1508 NW MOCK AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64015-3095
Practice Address - Country:US
Practice Address - Phone:816-228-7176
Practice Address - Fax:816-224-9555
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO139401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice