=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003961871
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JARED T KRIEGER DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 707 PENNSYLVANIA AVE SUITE 1200
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32701-6471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-478-5002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1307 TADSWORTH TER
-----------------------------------------------------
City | HEATHROW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32746-5333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-333-4644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | DN12734
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------