Provider Demographics
NPI:1952503104
Name:KLOOSTRA, PAUL WILLIAM (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WILLIAM
Last Name:KLOOSTRA
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 PENNSYLVANIA AVE 302
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3390
Mailing Address - Country:US
Mailing Address - Phone:304-388-2950
Mailing Address - Fax:304-388-2951
Practice Address - Street 1:830 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3302
Practice Address - Country:US
Practice Address - Phone:304-388-2950
Practice Address - Fax:304-388-2951
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV263131223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery