Provider Demographics
NPI:1740409663
Name:RED, CLARENCE JAMES III (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:JAMES
Last Name:RED
Suffix:III
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:227 N HAMMES AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8115
Mailing Address - Country:US
Mailing Address - Phone:815-744-2990
Mailing Address - Fax:815-744-8105
Practice Address - Street 1:227 N HAMMES AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8115
Practice Address - Country:US
Practice Address - Phone:815-744-2990
Practice Address - Fax:815-744-8105
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics