Basic Information
| Provider Information | |||||||||
| NPI: | 1952503104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLOOSTRA | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 PENNSYLVANIA AVE 302 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253023390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043882950 | ||||||||
| FaxNumber: | 3043882951 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 PENNSYLVANIA AVE | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253023302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043882950 | ||||||||
| FaxNumber: | 3043882951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 12/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 4100 | WV | N | Dental Providers | Dentist | Oral and Maxillofacial Surgery | 204E00000X | 26313 | WV | Y | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery |
No ID Information.