Active NPI
Breanna Kruckeberg, DMD
- General Practice Dentistry
- Madison Lake, MN
National Provider Identifier
1518339118
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- D13916
- Practice address
- 516 Main St
Madison Lake, MN 56063-2027 - Phone
- (507) 243-3747
- NPI assigned
- Oct 22, 2015
- Last updated
- Mar 13, 2025
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | D009327 | AZ | |
| Dentist | 122300000X | D13916 | MN | |
| General Practice Dentistry | 1223G0001X | D13916 | MN | Primary |
Addresses
Primary practice location
516 Main St
Madison Lake, MN 56063-2027
Mailing address
PO Box 458
Madison Lake, MN 56063-0458
Phone (507) 243-3747
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D13916 | MN | MD | General Practice Dentistry |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Bryan D. Johnson, DDS, PA | General Practice | Past | Accepting new patients |
| SP Dental | General Practice | Past | Accepting new patients |
| Joseph H Davis DDS PC | Dentist | Past | Accepting new patients |
Organizations & group practices 3
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- General Practice Dentistry
- Madison Lake, MN
- NPI 1043208267
-
- Dentist
- Phoenix, AZ
- NPI 1982852919
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1445472000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1741824000000",
"number": "1518339118",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 458",
"city": "MADISON LAKE",
"state": "MN",
"postal_code": "560630458",
"telephone_number": "507-243-3747"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "516 MAIN ST",
"city": "MADISON LAKE",
"state": "MN",
"postal_code": "560632027",
"telephone_number": "507-243-3747"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KRUCKEBERG",
"first_name": "BREANNA",
"credential": "DMD",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2015-10-22",
"last_updated": "2025-03-13",
"certification_date": "2025-03-13",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "AZ",
"license": "D009327",
"primary": false
},
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "MN",
"license": "D13916",
"primary": false
},
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "MN",
"license": "D13916",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Madison Lake, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 13, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.