=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205042413
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLEG KLUBIS D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5501 OLD YORK RD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19141-3018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-456-5892
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2979 W SCHOOL HOUSE LN # K903
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19144-5356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-844-0375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS035616
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------