Healthcare Provider Details

I. General information

NPI: 1205042413
Provider Name (Legal Business Name): OLEG KLUBIS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 OLD YORK RD
PHILADELPHIA PA
19141-3018
US

IV. Provider business mailing address

2979 W SCHOOL HOUSE LN # K903
PHILADELPHIA PA
19144-5356
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-5892
  • Fax:
Mailing address:
  • Phone: 215-844-0375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS035616
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: