Provider Demographics
NPI:1760121073
Name:KLABUNDE, ROBERT THEODORE
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:THEODORE
Last Name:KLABUNDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 PEACEFUL PL
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-7414
Mailing Address - Country:US
Mailing Address - Phone:507-227-6919
Mailing Address - Fax:
Practice Address - Street 1:8454 HIGHWAY 7
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-3900
Practice Address - Country:US
Practice Address - Phone:952-933-3667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND147221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND14722OtherDENTAL LICENSE NUMBER