Provider Demographics
NPI:1265505507
Name:CLEMENTS, FREDDIE THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:FREDDIE
Middle Name:THOMAS
Last Name:CLEMENTS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:FREDDIE
Other - Middle Name:T
Other - Last Name:CLEMENTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:409 ROLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:OWENTON
Mailing Address - State:KY
Mailing Address - Zip Code:40359-1401
Mailing Address - Country:US
Mailing Address - Phone:502-484-5888
Mailing Address - Fax:
Practice Address - Street 1:409 ROLAND AVENUE
Practice Address - Street 2:
Practice Address - City:OWENTON
Practice Address - State:KY
Practice Address - Zip Code:40359-1401
Practice Address - Country:US
Practice Address - Phone:502-484-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice