MEDICARE: DR. KELLY JAMES KLONTZ DDS MSD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	114	OK

General Provider Information

NPI Number	:	1720194897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY JAMES KLONTZ DDS MSD

Provider Business Mailing Address
First Line	:	9721 S PENNSYLVANIA AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-6900
Country	:	US
Telephone Number	:	405-691-8100
Fax Number	:	405-691-8204

Provider Business Practice Location Address
First Line	:	9721 S PENNSYLVANIA AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73159-6900
Country	:	US
Telephone Number	:	405-691-8100
Fax Number	:	405-691-8204

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/08/2007

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