Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 11753 | TX |
NPI | 1134132269 |
---|---|
Provider Name | Dr. Kenneth R. Krueger |
First Address | San Antonio, TX 78212-1905 |
Second Address | San Antonio, TX 78212-1905 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/08/2006 |
Last Update Date | 08/07/2007 |