MEDICARE: DR. R TODD KRUEGER D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	019-024078	IL

General Provider Information

NPI Number	:	1003211442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. R TODD KRUEGER D.M.D

Provider Business Mailing Address
First Line	:	213 S CLIFTON AVE
Second Line	:
City	:	MORTON
State	:	IL
Zip	:	61550-2033
Country	:	US
Telephone Number	:	309-263-0850
Fax Number	:	309-263-2308

Provider Business Practice Location Address
First Line	:	527 PULASKI ST
Second Line	:
City	:	LINCOLN
State	:	IL
Zip	:	62656-2773
Country	:	US
Telephone Number	:	309-263-0850
Fax Number	:	309-263-2308

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/28/2014
Last Update Date	:	10/28/2014

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