Healthcare Provider Details

I. General information

NPI: 1720194897
Provider Name (Legal Business Name): KELLY JAMES KLONTZ DDS MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
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: 405-691-8204
Mailing address:
  • Phone: 405-691-8100
  • Fax: 405-691-8204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number114
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: