Healthcare Provider Details

I. General information

NPI: 1346339595
Provider Name (Legal Business Name): YOUNGQUIST KENNEDY ORTHODONTICS, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 HAVENWOOD DR
LAKE GENEVA WI
53147-1917
US

IV. Provider business mailing address

255 HAVENWOOD DR
LAKE GENEVA WI
53147-1917
US

V. Phone/Fax

Practice location:
  • Phone: 262-248-0101
  • Fax: 262-248-2941
Mailing address:
  • Phone: 262-248-0101
  • Fax: 262-248-2941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2191B
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6951-15
License Number StateWI

VIII. Authorized Official

Name: DR. ROBERT R. YOUNGQUIST
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 262-248-0101