Provider Demographics
NPI:1962927517
Name:RONQUIST, KYLE RAYMOND (DDS)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:RAYMOND
Last Name:RONQUIST
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 STEIN BLVD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6978
Mailing Address - Country:US
Mailing Address - Phone:715-835-7172
Mailing Address - Fax:
Practice Address - Street 1:3131 STEIN BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6978
Practice Address - Country:US
Practice Address - Phone:715-835-7172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001663122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1001663-15OtherDENTAL LICENSE