Provider Demographics
NPI:1912031238
Name:KLOCKOW, BRUCE H (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:H
Last Name:KLOCKOW
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:W6750 MOHRBACH RD
Mailing Address - Street 2:
Mailing Address - City:PARK FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54552-6927
Mailing Address - Country:US
Mailing Address - Phone:715-762-3313
Mailing Address - Fax:
Practice Address - Street 1:370 3RD AVE S
Practice Address - Street 2:
Practice Address - City:PARK FALLS
Practice Address - State:WI
Practice Address - Zip Code:54552-1228
Practice Address - Country:US
Practice Address - Phone:715-762-2188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice