Healthcare Provider Details

I. General information

NPI: 1871852392
Provider Name (Legal Business Name): CHRISTOPHER GORDON KLABO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25477 MAIN ST
NISSWA MN
56468-5001
US

IV. Provider business mailing address

25477 MAIN ST
NISSWA MN
56468-5001
US

V. Phone/Fax

Practice location:
  • Phone: 189-636-3302
  • Fax:
Mailing address:
  • Phone: 218-963-6330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6976-15
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD13771
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: