Basic Information
Provider Information
NPI: 1003002882
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KRUCKEBERG
FirstName: SHANNON
MiddleName: MARIE
NamePrefix:  
NameSuffix:  
Credential: RDH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000XH6343MNY Dental ProvidersDental Hygienist 

No ID Information.


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