Provider Demographics
NPI:1881605921
Name:KLOCKOW, BRIAN D (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:D
Last Name:KLOCKOW
Suffix:
Gender:M
Credentials:DDS
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 161
Mailing Address - Street 2:
Mailing Address - City:WABENO
Mailing Address - State:WI
Mailing Address - Zip Code:54566-0161
Mailing Address - Country:US
Mailing Address - Phone:715-473-6711
Mailing Address - Fax:
Practice Address - Street 1:4488 N BRANCH ST
Practice Address - Street 2:
Practice Address - City:WABENO
Practice Address - State:WI
Practice Address - Zip Code:54566-0161
Practice Address - Country:US
Practice Address - Phone:715-473-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33386800Medicaid