Provider Demographics
NPI:1922398387
Name:CLIFFORD, MARY (RDH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:CLIFFORD
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 57TH ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-4146
Mailing Address - Country:US
Mailing Address - Phone:262-764-3622
Mailing Address - Fax:262-764-3636
Practice Address - Street 1:6226 14TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-4413
Practice Address - Country:US
Practice Address - Phone:262-656-0044
Practice Address - Fax:262-764-3636
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5460-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1922398387Medicaid