Provider Demographics
NPI:1447488911
Name:BERGQUIST, MICHAEL ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:BERGQUIST
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12002 SW 128TH CT
Mailing Address - Street 2:SUITE #108
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4639
Mailing Address - Country:US
Mailing Address - Phone:305-232-0074
Mailing Address - Fax:305-232-7110
Practice Address - Street 1:12002 SW 128TH CT
Practice Address - Street 2:SUITE #108
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4639
Practice Address - Country:US
Practice Address - Phone:305-232-0074
Practice Address - Fax:305-232-7110
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN161331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice