Provider Demographics
NPI:1508931205
Name:DANIEL W KRUEGER AAS PC
Entity Type:Organization
Organization Name:DANIEL W KRUEGER AAS PC
Other - Org Name:LIFESMILES DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-743-3779
Mailing Address - Street 1:928 N ROBINSON
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-2766
Mailing Address - Country:US
Mailing Address - Phone:765-743-3779
Mailing Address - Fax:765-743-8767
Practice Address - Street 1:928 N ROBINSON
Practice Address - Street 2:LIFESMILE DENTISTRY
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-2766
Practice Address - Country:US
Practice Address - Phone:765-743-3779
Practice Address - Fax:765-743-8767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010165A122300000X
IN12010165122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200270720BMedicaid
IN200270720BMedicaid