Provider Demographics
NPI:1871531228
Name:KRUEGER, DANIEL (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:KRUEGER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-7315
Mailing Address - Country:US
Mailing Address - Phone:765-491-1638
Mailing Address - Fax:
Practice Address - Street 1:2828 E STATE BLVD STE A
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4761
Practice Address - Country:US
Practice Address - Phone:260-482-6689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010165A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200270720BMedicaid
INU88457Medicare UPIN