Provider Demographics
NPI:1891957726
Name:KRALLYODER PC
Entity Type:Organization
Organization Name:KRALLYODER PC
Other - Org Name:METAMORA FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:KRALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:309-367-2378
Mailing Address - Street 1:212 N DAVENPORT ST
Mailing Address - Street 2:PO BOX 920
Mailing Address - City:METAMORA
Mailing Address - State:IL
Mailing Address - Zip Code:61548-9395
Mailing Address - Country:US
Mailing Address - Phone:309-369-2378
Mailing Address - Fax:
Practice Address - Street 1:212 N DAVENPORT ST
Practice Address - Street 2:
Practice Address - City:METAMORA
Practice Address - State:IL
Practice Address - Zip Code:61548-9395
Practice Address - Country:US
Practice Address - Phone:309-369-2378
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190258321223G0001X
IL0190187681223G0001X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty