Provider Demographics
NPI:1063478667
Name:CLEMENS, NICOLE M (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:M
Last Name:CLEMENS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1547
Mailing Address - Country:US
Mailing Address - Phone:608-254-2345
Mailing Address - Fax:608-254-6460
Practice Address - Street 1:245 W MUNROE AVE
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965-9656
Practice Address - Country:US
Practice Address - Phone:608-254-2345
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5961-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist