Provider Demographics
NPI:1215093364
Name:KLOCKENTEGER, LISA LOUISE (RDHAP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LOUISE
Last Name:KLOCKENTEGER
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 13TH STREET
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446
Mailing Address - Country:US
Mailing Address - Phone:805-237-0942
Mailing Address - Fax:805-237-1258
Practice Address - Street 1:503 13TH STREET
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446
Practice Address - Country:US
Practice Address - Phone:805-237-0942
Practice Address - Fax:805-237-1258
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA830444361OtherTAX ID NUMBER