Healthcare Provider Details

I. General information

NPI: 1851347017
Provider Name (Legal Business Name): GLENN R. STENQUIST D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W BUCHANAN ST SUITE 18
CALIFORNIA MO
65018-1238
US

IV. Provider business mailing address

24515 HIGHWAY D
CALIFORNIA MO
65018-2758
US

V. Phone/Fax

Practice location:
  • Phone: 573-796-8686
  • Fax: 573-796-5050
Mailing address:
  • Phone: 573-796-3420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number016038
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: