Provider Demographics
NPI:1225457328
Name:GARY D. KRUEGER, DDS, APC
Entity Type:Organization
Organization Name:GARY D. KRUEGER, DDS, APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MAXILLOFACIAL PROSTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-479-0961
Mailing Address - Street 1:320 SANTA FE DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5140
Mailing Address - Country:US
Mailing Address - Phone:760-479-0961
Mailing Address - Fax:760-479-0963
Practice Address - Street 1:320 SANTA FE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5138
Practice Address - Country:US
Practice Address - Phone:760-479-0961
Practice Address - Fax:760-479-0963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY423471223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD42347Medicare UPIN