Provider Demographics
NPI:1851450837
Name:HERMUNSLIE, CLARICE IONE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLARICE
Middle Name:IONE
Last Name:HERMUNSLIE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:CLARICE
Other - Middle Name:
Other - Last Name:SHUSTERICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10803 57TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-1659
Mailing Address - Country:US
Mailing Address - Phone:763-553-2692
Mailing Address - Fax:
Practice Address - Street 1:8559 EDINBROOK PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3747
Practice Address - Country:US
Practice Address - Phone:763-425-3644
Practice Address - Fax:763-425-0953
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND98311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice