Provider Demographics
NPI:1689687014
Name:DILL, CLARENCE W III (DDS)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:W
Last Name:DILL
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:BILL
Other - Middle Name:CW
Other - Last Name:DILL
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2646 E JOYCE BOULEVARD SUITE #1
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703
Mailing Address - Country:US
Mailing Address - Phone:479-443-4440
Mailing Address - Fax:479-443-4450
Practice Address - Street 1:2646 E JOYCE BOULEVARD SUITE #1
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-443-4440
Practice Address - Fax:479-443-4450
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR20751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR160839608Medicaid