MEDICARE: RONALD CARL BERQUIST DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0327	CO

General Provider Information

NPI Number	:	1629151014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONALD CARL BERQUIST DDS

Provider Business Mailing Address
First Line	:	829 CHIEF EDDIE HOFFMAN HWY
Second Line	:
City	:	BETHEL
State	:	AK
Zip	:	99559-0528
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	829 CHIEF EDDIE HOFFMAN HWY
Second Line	:
City	:	BETHEL
State	:	AK
Zip	:	99559-0528
Country	:	US
Telephone Number	:	907-543-6229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	08/19/2008

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