Provider Demographics
NPI:1003002882
Name:KRUCKEBERG, SHANNON MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:KRUCKEBERG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63407 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:MN
Mailing Address - Zip Code:55924-4656
Mailing Address - Country:US
Mailing Address - Phone:507-319-6845
Mailing Address - Fax:
Practice Address - Street 1:63407 130TH AVE
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:MN
Practice Address - Zip Code:55924-4656
Practice Address - Country:US
Practice Address - Phone:507-319-6845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH6343124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist