Provider Demographics
NPI:1386679546
Name:CLEMENS, DENNIS MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:MARK
Last Name:CLEMENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 TRENWEST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3208
Mailing Address - Country:US
Mailing Address - Phone:336-970-5000
Mailing Address - Fax:336-970-5298
Practice Address - Street 1:3155 MAPLEWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-794-4372
Practice Address - Fax:336-659-2379
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC334852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891272NMedicaid
NC2282602KMedicare PIN
NC2282602FMedicare PIN
E41813Medicare UPIN
NC2282602GMedicare PIN
NC2282602JMedicare PIN
NC2282602HMedicare PIN
NC891272NMedicaid