Healthcare Provider Details

I. General information

NPI: 1932205416
Provider Name (Legal Business Name): THOMAS EDWIN KLAG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

IV. Provider business mailing address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

V. Phone/Fax

Practice location:
  • Phone: 405-270-5139
  • Fax:
Mailing address:
  • Phone: 405-270-5139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5195
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number5509
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2640
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: