Provider Demographics
NPI:1518339118
Name:KRUCKEBERG, BREANNA (DMD)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:KRUCKEBERG
Suffix:
Gender:F
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:PO BOX 458
Mailing Address - Street 2:
Mailing Address - City:MADISON LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56063-0458
Mailing Address - Country:US
Mailing Address - Phone:507-243-3747
Mailing Address - Fax:
Practice Address - Street 1:516 MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON LAKE
Practice Address - State:MN
Practice Address - Zip Code:56063-2027
Practice Address - Country:US
Practice Address - Phone:507-243-3747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009327122300000X
MND13916122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist