Provider Demographics
NPI:1710105630
Name:KEITH D. CLEMENCE, DDS
Entity Type:Organization
Organization Name:KEITH D. CLEMENCE, DDS
Other - Org Name:CLEMENCE DENTAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLEMENCE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-425-0120
Mailing Address - Street 1:5751 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-1940
Mailing Address - Country:US
Mailing Address - Phone:414-425-0120
Mailing Address - Fax:414-425-0978
Practice Address - Street 1:5751 S 108TH ST
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-1940
Practice Address - Country:US
Practice Address - Phone:414-425-0120
Practice Address - Fax:414-425-0978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50015581223G0001X
WI50014591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty