Provider Demographics
NPI:1912427642
Name:KRUEGER, NATHAN PHILLIP (DMD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:PHILLIP
Last Name:KRUEGER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14233 W VIA MANANA
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-2238
Mailing Address - Country:US
Mailing Address - Phone:928-503-4336
Mailing Address - Fax:
Practice Address - Street 1:4660 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8507
Practice Address - Country:US
Practice Address - Phone:920-730-0345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001603122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist