Provider Demographics
NPI:1518451707
Name:KROEKER, CLINT MATTHEW (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:MATTHEW
Last Name:KROEKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:CLINT
Other - Middle Name:
Other - Last Name:KROEKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1545 LIVINGSTON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:WEST ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-3422
Mailing Address - Country:US
Mailing Address - Phone:651-455-0505
Mailing Address - Fax:
Practice Address - Street 1:1545 LIVINGSTON AVE STE 101
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3422
Practice Address - Country:US
Practice Address - Phone:651-455-0505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14069122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist