=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316433204
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KLOCH FAMILY DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2018
-----------------------------------------------------
Last Update Date | 07/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1602 HIGHWAY 17 N
-----------------------------------------------------
City | SURFSIDE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29575-6015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-238-3332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 74 PIPEDOWN WAY
-----------------------------------------------------
City | PAWLEYS ISLAND
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29585-6526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-833-7247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. ANDREW S KLOCH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 843-833-7247
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------