Provider Demographics
NPI:1699126144
Name:KRUM, JONATHAN G (PHD, DMD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:G
Last Name:KRUM
Suffix:
Gender:M
Credentials:PHD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BELLE FOURCHE
Mailing Address - State:SD
Mailing Address - Zip Code:57717-1716
Mailing Address - Country:US
Mailing Address - Phone:605-892-6347
Mailing Address - Fax:605-892-9027
Practice Address - Street 1:503 JACKSON ST
Practice Address - Street 2:
Practice Address - City:BELLE FOURCHE
Practice Address - State:SD
Practice Address - Zip Code:57717-1716
Practice Address - Country:US
Practice Address - Phone:605-892-6347
Practice Address - Fax:605-892-9027
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD1119122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist