=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811545049
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHAN KLABUNDE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2019
-----------------------------------------------------
Last Update Date | 08/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 NORTHWOODS BLVD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43235-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-848-4900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1370 WINGATE DR
-----------------------------------------------------
City | DELAWARE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43015-9200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-348-2909
-----------------------------------------------------
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 | 30.025971
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------