Basic Information
| Provider Information | |||||||||
| NPI: | 1003002882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRUCKEBERG | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 63407 130TH AVE | ||||||||
| Address2: | |||||||||
| City: | CLAREMONT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559244656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073196845 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 63407 130TH AVE | ||||||||
| Address2: | |||||||||
| City: | CLAREMONT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559244656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073196845 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2007 | ||||||||
| LastUpdateDate: | 11/16/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | H6343 | MN | Y | Dental Providers | Dental Hygienist |
No ID Information.