Healthcare Provider Details

I. General information

NPI: 1700893989
Provider Name (Legal Business Name): KEN KLOESS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 S MAIN ST
DUPO IL
62239-1357
US

IV. Provider business mailing address

240 S MAIN ST
DUPO IL
62239-1357
US

V. Phone/Fax

Practice location:
  • Phone: 618-286-4855
  • Fax: 618-286-5945
Mailing address:
  • Phone: 618-286-4855
  • Fax: 618-286-5945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: