Healthcare Provider Details

I. General information

NPI: 1720044126
Provider Name (Legal Business Name): KEITH EDWARD KRUEGER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 SW CHANDLER AVE SUITE 101
BEND OR
97702-3238
US

IV. Provider business mailing address

1475 SW CHANDLER AVE SUITE 101
BEND OR
97702-3238
US

V. Phone/Fax

Practice location:
  • Phone: 541-617-3993
  • Fax: 541-617-0030
Mailing address:
  • Phone: 541-617-3993
  • Fax: 541-617-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberD6629
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: