Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | D6629 | OR |
NPI | 1720044126 |
---|---|
Provider Name | Dr. Keith Edward Krueger |
First Address | Bend, OR 97702-3238 |
Second Address | Bend, OR 97702-3238 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2006 |
Last Update Date | 08/07/2007 |