Provider Demographics
NPI:1104978378
Name:KLEITZ, RANDALL ALLEN (DMD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:ALLEN
Last Name:KLEITZ
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 1:13603 BARRETT OFFICE DRIVE
Mailing Address - Street 2:STE 104
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7828
Mailing Address - Country:US
Mailing Address - Phone:314-822-3868
Mailing Address - Fax:314-822-1101
Practice Address - Street 1:13603 BARRETT OFFICE DRIVE
Practice Address - Street 2:STE 104
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63021-7828
Practice Address - Country:US
Practice Address - Phone:314-822-3868
Practice Address - Fax:314-822-1101
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO122221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice