Provider Demographics
NPI:1124249958
Name:KRUSE, FREDERICK CLYDE (DDS)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:CLYDE
Last Name:KRUSE
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 1:9350 SYLVANIA
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560
Mailing Address - Country:US
Mailing Address - Phone:419-829-6304
Mailing Address - Fax:
Practice Address - Street 1:3015 NAVARRE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3398
Practice Address - Country:US
Practice Address - Phone:419-693-8993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14964122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0292062Medicaid