Provider Demographics
NPI:1932940764
Name:BERGQUIST, AUDRA DEE (DDS)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:DEE
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:WAKEENEY
Mailing Address - State:KS
Mailing Address - Zip Code:67672-1911
Mailing Address - Country:US
Mailing Address - Phone:785-259-0678
Mailing Address - Fax:
Practice Address - Street 1:850 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-3673
Practice Address - Country:US
Practice Address - Phone:660-646-3802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20240204301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice