Provider Demographics
NPI:1326499807
Name:KLUCZNIK, DAVID (DMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:KLUCZNIK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 SAINT ANDREWS RD
Mailing Address - Street 2:
Mailing Address - City:MOYOCK
Mailing Address - State:NC
Mailing Address - Zip Code:27958-9363
Mailing Address - Country:US
Mailing Address - Phone:252-455-0492
Mailing Address - Fax:
Practice Address - Street 1:5564 INDIAN RIVER ROAD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464
Practice Address - Country:US
Practice Address - Phone:757-366-5084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103731223G0001X
VA0414152091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice