Provider Demographics
NPI:1851406748
Name:KRUSE, BRIAN L (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:KRUSE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 N PINE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-3543
Mailing Address - Country:US
Mailing Address - Phone:541-963-6445
Mailing Address - Fax:541-963-9012
Practice Address - Street 1:1502 N PINE ST STE 2
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-3543
Practice Address - Country:US
Practice Address - Phone:541-963-6445
Practice Address - Fax:541-963-9012
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD77961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice