Provider Demographics
NPI:1598818494
Name:KRAIG, JEFFREY JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JAMES
Last Name:KRAIG
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 1:145 S MARR ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4434
Mailing Address - Country:US
Mailing Address - Phone:920-922-9000
Mailing Address - Fax:920-922-9025
Practice Address - Street 1:145 S MARR ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4434
Practice Address - Country:US
Practice Address - Phone:920-922-9000
Practice Address - Fax:920-922-9025
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1891-G122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33352200Medicaid