Basic Information
| Provider Information | |||||||||
| NPI: | 1538560743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLISH | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1811 ARMY BLVD BLDG 2018 | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782342686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102210826 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1811 ARMY BLVD BLDG 2018 | ||||||||
| Address2: | |||||||||
| City: | FORT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782342686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102210826 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2014 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 15608 | MD | Y | Dental Providers | Dentist | General Practice |
No ID Information.