Healthcare Provider Details

I. General information

NPI: 1629162425
Provider Name (Legal Business Name): JAY LYNN KRUSKA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 NORTH BROADWAY
HOBART OK
73651
US

IV. Provider business mailing address

PO BOX 779
HOBART OK
73651-0779
US

V. Phone/Fax

Practice location:
  • Phone: 580-726-2524
  • Fax: 580-726-3425
Mailing address:
  • Phone: 580-726-2524
  • Fax: 580-726-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4255
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: