Provider Demographics
NPI:1497015721
Name:G.R. CLEMENS, D.D.S., P.C.
Entity Type:Organization
Organization Name:G.R. CLEMENS, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:G.
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLEMENS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-795-1255
Mailing Address - Street 1:3340 OAK PARK AVE.
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3483
Mailing Address - Country:US
Mailing Address - Phone:708-795-1255
Mailing Address - Fax:708-795-1215
Practice Address - Street 1:3340 OAK PARK AVE.
Practice Address - Street 2:SUITE 301
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3483
Practice Address - Country:US
Practice Address - Phone:708-795-1255
Practice Address - Fax:708-795-1215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL190156581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty