Provider Demographics
NPI:1699205336
Name:CLANCY, PATRICK T (DDS)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:T
Last Name:CLANCY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11904 W NORTH AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2062
Mailing Address - Country:US
Mailing Address - Phone:608-225-4856
Mailing Address - Fax:
Practice Address - Street 1:11904 W NORTH AVE STE 105
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2062
Practice Address - Country:US
Practice Address - Phone:414-454-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001596-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice