Provider Demographics
NPI:1861861254
Name:KLOCKOW PC
Entity type:Organization
Organization Name:KLOCKOW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:KLOCKOW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:219-869-1097
Mailing Address - Street 1:118 S VAN RENSSELAER ST
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-2815
Mailing Address - Country:US
Mailing Address - Phone:219-869-1097
Mailing Address - Fax:219-267-1729
Practice Address - Street 1:118 S VAN RENSSELAER ST
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-2815
Practice Address - Country:US
Practice Address - Phone:219-869-1097
Practice Address - Fax:219-267-1729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54000437A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental