Provider Demographics
NPI:1255889788
Name:BERQUIST, DEREK ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:ROBERT
Last Name:BERQUIST
Suffix:
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 1:9044 BUNKER HILL DR
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3203
Mailing Address - Country:US
Mailing Address - Phone:219-765-7468
Mailing Address - Fax:
Practice Address - Street 1:11059 BROADWAY
Practice Address - Street 2:SUITE B
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8834
Practice Address - Country:US
Practice Address - Phone:219-226-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012546A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist