Provider Demographics
NPI:1962013136
Name:CRUCIGER, MICHAEL WILLIAM (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:CRUCIGER
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 1:1100 WILFORD HALL LOOP BLDG 4554
Mailing Address - Street 2:
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5638
Mailing Address - Country:US
Mailing Address - Phone:212-292-0680
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP BLDG 4554
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5638
Practice Address - Country:US
Practice Address - Phone:210-292-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT118904339921122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist