Provider Demographics
NPI:1013921816
Name:KLEBANOW, DAVID A (DMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:KLEBANOW
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 1:105 HILLSIDE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-2311
Mailing Address - Country:US
Mailing Address - Phone:516-742-2820
Mailing Address - Fax:516-742-7846
Practice Address - Street 1:105 HILLSIDE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-2311
Practice Address - Country:US
Practice Address - Phone:516-742-2820
Practice Address - Fax:516-742-7846
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0349521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice