Provider Demographics
NPI:1598783664
Name:KRUEGER, GARY DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:DOUGLAS
Last Name:KRUEGER
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 1:320 SANTA FE DR
Mailing Address - Street 2:SUITE #201
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5138
Mailing Address - Country:US
Mailing Address - Phone:760-479-0961
Mailing Address - Fax:760-479-0963
Practice Address - Street 1:320 SANTA FE DR
Practice Address - Street 2:SUITE #201
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5138
Practice Address - Country:US
Practice Address - Phone:760-479-0961
Practice Address - Fax:760-479-0963
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA423471223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD42347Medicare UPIN