Healthcare Provider Details

I. General information

NPI: 1114910668
Provider Name (Legal Business Name): BERNARD IAN KRUPP DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220B E JOPPA RD SUITE 314
TOWSON MD
21286-5813
US

IV. Provider business mailing address

1220B E JOPPA RD SUITE 314
TOWSON MD
21286-5813
US

V. Phone/Fax

Practice location:
  • Phone: 410-583-7600
  • Fax: 410-583-9669
Mailing address:
  • Phone: 410-583-7600
  • Fax: 410-583-9669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7754
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: