MEDICARE: DR. JOHN WILLIAM CRETZMEYER JR. DDS

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	8144	MN

General Provider Information

NPI Number	:	1164403267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN WILLIAM CRETZMEYER JR. DDS

Provider Business Mailing Address
First Line	:	1099 MOORE LAKE DR E
Second Line	:
City	:	FRIDLEY
State	:	MN
Zip	:	55432-5153
Country	:	US
Telephone Number	:	763-586-9988
Fax Number	:	763-586-9977

Provider Business Practice Location Address
First Line	:	1099 MOORE LAKE DR E
Second Line	:
City	:	FRIDLEY
State	:	MN
Zip	:	55432-5153
Country	:	US
Telephone Number	:	763-586-9988
Fax Number	:	763-586-9977

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

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	01/20/2011

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