Provider Demographics
NPI:1811040298
Name:KLOBERDANZ ORAL SURGERY AND DENTAL IMPLANTS P.C.
Entity Type:Organization
Organization Name:KLOBERDANZ ORAL SURGERY AND DENTAL IMPLANTS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-377-7077
Mailing Address - Street 1:2580 FOXFIELD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1411
Mailing Address - Country:US
Mailing Address - Phone:630-377-7077
Mailing Address - Fax:
Practice Address - Street 1:2580 FOXFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1411
Practice Address - Country:US
Practice Address - Phone:630-377-7077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203640Medicare ID - Type Unspecified
IL730710Medicare ID - Type Unspecified