Provider Demographics
NPI:1538551304
Name:YOUNGQUIST, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:YOUNGQUIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 HAVENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE GENEVA
Mailing Address - State:WI
Mailing Address - Zip Code:53147-1988
Mailing Address - Country:US
Mailing Address - Phone:262-248-0101
Mailing Address - Fax:
Practice Address - Street 1:255 HAVENWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-1988
Practice Address - Country:US
Practice Address - Phone:262-248-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21911223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics