Provider Demographics
NPI:1982920955
Name:KLOKKEVOLD, PERRY RICHARD (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:PERRY
Middle Name:RICHARD
Last Name:KLOKKEVOLD
Suffix:
Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:100 MEDICAL PLAZA
Mailing Address - Street 2:SUITE #320
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1668
Mailing Address - Country:US
Mailing Address - Phone:310-206-6252
Mailing Address - Fax:310-825-1903
Practice Address - Street 1:100 UCLA MEDICAL PLAZA
Practice Address - Street 2:SUITE #320
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1668
Practice Address - Country:US
Practice Address - Phone:310-206-6252
Practice Address - Fax:310-825-1903
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA346231223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics