Provider Demographics
NPI:1669554895
Name:KROEGER, JERRY A (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:A
Last Name:KROEGER
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 1:249 CHERRY HILL BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2645
Mailing Address - Country:US
Mailing Address - Phone:402-488-2383
Mailing Address - Fax:402-488-2384
Practice Address - Street 1:249 CHERRY HILL BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2645
Practice Address - Country:US
Practice Address - Phone:402-488-2383
Practice Address - Fax:402-488-2384
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE39001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470522452-00Medicaid
NE05731OtherBLUECROSS BLUESHIELD