Provider Demographics
NPI:1255582219
Name:WILLIAM A. KLENK DDS, INC.
Entity type:Organization
Organization Name:WILLIAM A. KLENK DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:KLENK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-658-5282
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:26496 MIDLAND TRAIL
Mailing Address - City:HICO
Mailing Address - State:WV
Mailing Address - Zip Code:25854-0497
Mailing Address - Country:US
Mailing Address - Phone:304-658-5282
Mailing Address - Fax:304-658-5299
Practice Address - Street 1:26496 MIDLAND TRAIL
Practice Address - Street 2:
Practice Address - City:HICO
Practice Address - State:WV
Practice Address - Zip Code:25854-0497
Practice Address - Country:US
Practice Address - Phone:304-658-5282
Practice Address - Fax:304-658-5299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV 28641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0132483000Medicaid