Jalissa Joy Kruckman, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D12793 Issued in MN

Practice address

576 Cherry Dr
Waconia, MN 55387

Phone

(952) 679-4461

NPI assigned

Jun 28, 2010

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Nov 16, 2018 through Nov 16, 2026

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Kruckman Family Dentistry

  • Dental Clinic/Center
  • Waconia, MN
  • NPI 1457134785
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1277683200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1531699200000",
    "number": "1114238821",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "576 CHERRY DR",
            "city": "WACONIA",
            "state": "MN",
            "postal_code": "553874578",
            "telephone_number": "952-679-4461"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "576 CHERRY DR",
            "city": "WACONIA",
            "state": "MN",
            "postal_code": "55387",
            "telephone_number": "952-679-4461"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KRUCKMAN",
        "first_name": "JALISSA",
        "middle_name": "JOY",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2010-06-28",
        "last_updated": "2018-07-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "D12793",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Alexandra Kothenbeutel
• Charity Kranz, DO
• Krista D Kranz, CNM
• Benjamin Dreyer Krehbiel, DO
• Kruckman Family Dentistry
• Emily Kruger, LICSW
• Emily Kubat, DPT
• Lindsay Kugel
• Cassandra Kuntz, OTR/L
• Kendra Kurtz, LADC

• General Practice Dentistry in Waconia, MN
• Providers in Waconia, MN by specialty
• General Practice Dentistry in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 16, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.