Provider Demographics
NPI:1295824555
Name:KRALICKE, STEPHEN MARK (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARK
Last Name:KRALICKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:STEVE
Other - Middle Name:M
Other - Last Name:KRALICKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2620 HARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-3700
Mailing Address - Country:US
Mailing Address - Phone:817-267-6101
Mailing Address - Fax:817-571-5456
Practice Address - Street 1:2620 HARWOOD RD
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-3700
Practice Address - Country:US
Practice Address - Phone:817-267-6101
Practice Address - Fax:817-571-5456
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice