Provider Demographics
NPI:1780687293
Name:CLAUSSEN, DALE GLEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:GLEN
Last Name:CLAUSSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 SAINT LOUIS ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-1504
Mailing Address - Country:US
Mailing Address - Phone:618-656-0201
Mailing Address - Fax:
Practice Address - Street 1:620 SAINT LOUIS ST
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-1504
Practice Address - Country:US
Practice Address - Phone:618-656-0201
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19 158441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice