Provider Demographics
NPI:1972598357
Name:KLOUCEK, JOHN DALE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DALE
Last Name:KLOUCEK
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:PO BOX 1757
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97075-1757
Mailing Address - Country:US
Mailing Address - Phone:503-626-0998
Mailing Address - Fax:503-626-0988
Practice Address - Street 1:4130 SW 100TH AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005
Practice Address - Country:US
Practice Address - Phone:503-626-0998
Practice Address - Fax:503-626-0988
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD63581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice