Provider Demographics
NPI:1013019694
Name:CLEMENS, MARK ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:CLEMENS
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 1:502 SHAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-1957
Mailing Address - Country:US
Mailing Address - Phone:913-651-2115
Mailing Address - Fax:913-682-1218
Practice Address - Street 1:502 SHAWNEE ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-1957
Practice Address - Country:US
Practice Address - Phone:913-651-2115
Practice Address - Fax:913-682-1218
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist