Healthcare Provider Details

I. General information

NPI: 1003290545
Provider Name (Legal Business Name): KELLY KLONTZ DDS,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9721 S PENNSYLVANIA AVE
OKLAHOMA CITY OK
73159-6900
US

IV. Provider business mailing address

9721 S PENNSYLVANIA AVE
OKLAHOMA CITY OK
73159-6900
US

V. Phone/Fax

Practice location:
  • Phone: 405-691-8100
  • Fax:
Mailing address:
  • Phone: 405-691-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4878
License Number StateOK

VIII. Authorized Official

Name: KELLY JAMES KLONTZ
Title or Position: OWNER
Credential: DDS
Phone: 405-691-8100