Healthcare Provider Details

I. General information

NPI: 1750453049
Provider Name (Legal Business Name): DAVID EDMUND KRIGBAUM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 STEWART AVE SUITE 218
WAUSAU WI
54401-4170
US

IV. Provider business mailing address

2620 STEWART AVE SUITE 218
WAUSAU WI
54401-4170
US

V. Phone/Fax

Practice location:
  • Phone: 715-842-8811
  • Fax: 715-848-5109
Mailing address:
  • Phone: 715-842-8811
  • Fax: 715-848-5109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4501
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: