Provider Demographics
NPI:1912064189
Name:KLUM, LEEANNE MARIE (DDS)
Entity Type:Individual
Prefix:MRS
First Name:LEEANNE
Middle Name:MARIE
Last Name:KLUM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 FAVOR DR
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-1170
Mailing Address - Country:US
Mailing Address - Phone:608-637-2655
Mailing Address - Fax:608-637-2298
Practice Address - Street 1:1225 FAVOR DR
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-1170
Practice Address - Country:US
Practice Address - Phone:608-637-2655
Practice Address - Fax:608-637-2298
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6000-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice