Provider Demographics
NPI:1003429465
Name:KLINKENBERG, PETER MAROT (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:MAROT
Last Name:KLINKENBERG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 OLD CEDAR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1647
Mailing Address - Country:US
Mailing Address - Phone:612-964-5865
Mailing Address - Fax:
Practice Address - Street 1:1464 WHITE OAK DR
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2525
Practice Address - Country:US
Practice Address - Phone:952-351-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND114611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice