Provider Demographics
NPI:1740274422
Name:CRONKRITE, JOHN G (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:CRONKRITE
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 1:221 ALEXANDER AVE
Mailing Address - Street 2:
Mailing Address - City:PORT EDWARDS
Mailing Address - State:WI
Mailing Address - Zip Code:54469-1327
Mailing Address - Country:US
Mailing Address - Phone:715-887-4308
Mailing Address - Fax:
Practice Address - Street 1:211 MARKET AVE
Practice Address - Street 2:
Practice Address - City:PORT EDWARDS
Practice Address - State:WI
Practice Address - Zip Code:54469-1347
Practice Address - Country:US
Practice Address - Phone:715-887-2000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001688-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33376000Medicaid