Provider Demographics
NPI:1578615027
Name:JURECKO, KEVIN R (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:JURECKO
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 1:2086 SW MAIN BLVD
Mailing Address - Street 2:SUITE #113
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0005
Mailing Address - Country:US
Mailing Address - Phone:386-758-6050
Mailing Address - Fax:386-758-7742
Practice Address - Street 1:2086 SW MAIN BLVD
Practice Address - Street 2:SUITE #113
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0005
Practice Address - Country:US
Practice Address - Phone:386-758-6050
Practice Address - Fax:386-758-7742
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00054181223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics