Provider Demographics
NPI:1164693263
Name:CLEMENT, CHAD ELLIOTT
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:ELLIOTT
Last Name:CLEMENT
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:CHAD
Other - Middle Name:ELLIOTT
Other - Last Name:CLEMENT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 1487
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-0075
Mailing Address - Country:US
Mailing Address - Phone:541-997-3423
Mailing Address - Fax:541-997-8749
Practice Address - Street 1:1256 BAY ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-9648
Practice Address - Country:US
Practice Address - Phone:541-997-3423
Practice Address - Fax:541-997-8749
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8497122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist