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General NPI Number Information
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NPI Number | 1346339595
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Entity Type | Organization
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Legal Business Name | YOUNGQUIST KENNEDY ORTHODONTICS, LTD.
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Dates
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Enumeration Date | 10/12/2006
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Last Update Date | 09/25/2017
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Provider Practice Location Address
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Address Line | 255 HAVENWOOD DR
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City | LAKE GENEVA
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State | WI
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Zip | 53147-1917
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Country | US
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Telephone | 262-248-0101
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Fax | 262-248-2941
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Provider Business Mailing Address
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Address Line | 255 HAVENWOOD DR
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City | LAKE GENEVA
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State | WI
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Zip | 53147-1917
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Country | US
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Telephone | 262-248-0101
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Fax | 262-248-2941
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROBERT R. YOUNGQUIST
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Credential | D.D.S.
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Telephone | 262-248-0101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 2191B
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 6951-15
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License Number State | WI
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