Provider Demographics
NPI:1003971789
Name:PRINCE, CLIFFORD (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLIFFORD
Middle Name:
Last Name:PRINCE
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 1:4535 OAKTON ST
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-3117
Mailing Address - Country:US
Mailing Address - Phone:847-675-4535
Mailing Address - Fax:847-675-2780
Practice Address - Street 1:4535 OAKTON ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-3117
Practice Address - Country:US
Practice Address - Phone:847-675-4535
Practice Address - Fax:847-675-2780
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-A15561122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist