Healthcare Provider Details

I. General information

NPI: 1699373829
Provider Name (Legal Business Name): DONALD JAY BERQUIST JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2020
Last Update Date: 10/10/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 E 92ND ST
CHICAGO IL
60617-4598
US

IV. Provider business mailing address

696 LONGFELLOW DR
TROY MI
48085-4817
US

V. Phone/Fax

Practice location:
  • Phone: 773-295-2521
  • Fax:
Mailing address:
  • Phone: 248-672-8903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019032682
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: