Provider Demographics
NPI:1114515061
Name:CLEMENS, MICHAEL ALEXANDER (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALEXANDER
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 1:6950 NE CAMPUS WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5611
Mailing Address - Country:US
Mailing Address - Phone:855-433-6825
Mailing Address - Fax:
Practice Address - Street 1:3866 S 74TH ST STE 200
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-9908
Practice Address - Country:US
Practice Address - Phone:855-433-6825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-06
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE611045371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice