Healthcare Provider Details

I. General information

NPI: 1104490689
Provider Name (Legal Business Name): KREKLOW DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 NW 2ND AVE
GRAND RAPIDS MN
55744-2627
US

IV. Provider business mailing address

510 NW 2ND AVE
GRAND RAPIDS MN
55744-2627
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-1266
  • Fax:
Mailing address:
  • Phone: 218-326-1266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GRETCHEN MARIE KREKLOW
Title or Position: PROVIDER
Credential: DDS
Phone: 218-831-7246