Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 29913 | CA |
NPI | 1093883274 |
---|---|
Provider Name | Dr. Criag R Bergquist |
First Address | San Clemente, CA 92673 |
Second Address | San Clemente, CA 92673 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2006 |
Last Update Date | 08/07/2007 |