DEREK R BERQUIST Dentist License verification

Business Entity

NOT RENEWED

License Type

Dentist

Description

LICENSED DENTIST CONTROLLED SUBSTANCE

License Number

31*****68

License Status

NOT RENEWED

Business

First Name

DEREK

Middle

Last Name

BERQUIST

Business Name

DEREK R BERQUIST

Original Issue Date

06/24/2016

Effective Date

06/24/2016

Expiration Date

09/30/2018

City

MUNSTER

State

Zip

46321

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

10/31/2018