Provider Demographics
NPI:1326012048
Name:KRYSZAK, DAVID JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:KRYSZAK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21ST STREET
Mailing Address - Street 2:BLDG 2441
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5369
Mailing Address - Country:US
Mailing Address - Phone:270-798-8614
Mailing Address - Fax:270-798-8633
Practice Address - Street 1:21ST STREET
Practice Address - Street 2:BLDG 2441
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5369
Practice Address - Country:US
Practice Address - Phone:270-798-8614
Practice Address - Fax:270-798-8633
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10665122300000X, 1223G0001X
WI3902122300000X, 1223G0001X
TN8227122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223G0001XDental ProvidersDentistGeneral Practice