Healthcare Provider Details

I. General information

NPI: 1629087929
Provider Name (Legal Business Name): JEFFREY MICHAEL KRATKY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9911 KENNERLY RD STE. E
SAINT LOUIS MO
63128-2700
US

IV. Provider business mailing address

100 CRESCENT BLUFF DR
EUREKA MO
63025-1631
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-4699
  • Fax: 314-842-3074
Mailing address:
  • Phone: 636-938-1040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number015971
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: