Provider Demographics
NPI:1427152909
Name:KLEMZ, CHARLES B (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:B
Last Name:KLEMZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1383 21ST AVE N
Mailing Address - Street 2:SUITE B
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-1841
Mailing Address - Country:US
Mailing Address - Phone:701-237-3517
Mailing Address - Fax:701-293-9718
Practice Address - Street 1:1383 21ST AVE N
Practice Address - Street 2:SUITE B
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-1841
Practice Address - Country:US
Practice Address - Phone:701-237-3517
Practice Address - Fax:701-293-9718
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND15451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND040591Medicaid
ND1545OtherDSC PROVIDER NUMBER
NDAK7263293OtherDEA
ND450336537OtherTAX ID NUMBER