Provider Demographics
NPI:1093809451
Name:CLOVE, WENDELL DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:DAVID
Last Name:CLOVE
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 1:152 CATHERINE LN
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5756
Mailing Address - Country:US
Mailing Address - Phone:530-273-9111
Mailing Address - Fax:530-274-7937
Practice Address - Street 1:152 CATHERINE LN
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5756
Practice Address - Country:US
Practice Address - Phone:530-273-9111
Practice Address - Fax:530-274-7937
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA465751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB46575-01Medicaid