Provider Demographics
NPI:1124224522
Name:MOLLSEN, CLIFFORD MICHAEL JR (DDS)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:MICHAEL
Last Name:MOLLSEN
Suffix:JR
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 1:1455 EAST GOLF ROAD
Mailing Address - Street 2:SUITE 118
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016
Mailing Address - Country:US
Mailing Address - Phone:847-824-5044
Mailing Address - Fax:847-824-9530
Practice Address - Street 1:1455 EAST GOLF ROAD
Practice Address - Street 2:SUITE 118
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016
Practice Address - Country:US
Practice Address - Phone:847-824-5044
Practice Address - Fax:847-824-9530
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19A12965122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist