1699259606 NPI number — CD OHIO DERRICK KRUGER DDS, INC.

Table of content: (NPI 1699259606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699259606 NPI number — CD OHIO DERRICK KRUGER DDS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CD OHIO DERRICK KRUGER DDS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699259606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9825 KENWOOD RD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLUE ASH
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45242-6252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-808-4984
Provider Business Mailing Address Fax Number:
513-448-0511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4157 HUNT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUE ASH
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45236-1158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-791-6154
Provider Business Practice Location Address Fax Number:
513-791-1449
Provider Enumeration Date:
09/17/2018

Additional Information

Authorized Official

Authorized Official Last Name:
JUSTICE
Authorized Official First Name:
TY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, CREDENTIALING & PAYER REL
Authorized Official Telephone Number:
513-808-4984

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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