Provider Demographics
NPI:1922664648
Name:CLEMENSON, MORGAN
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:
Last Name:CLEMENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1279 270TH AVE
Mailing Address - Street 2:
Mailing Address - City:LUCK
Mailing Address - State:WI
Mailing Address - Zip Code:54853-4103
Mailing Address - Country:US
Mailing Address - Phone:715-554-4440
Mailing Address - Fax:
Practice Address - Street 1:601 STATE ROAD 35
Practice Address - Street 2:
Practice Address - City:CENTURIA
Practice Address - State:WI
Practice Address - Zip Code:54824-9014
Practice Address - Country:US
Practice Address - Phone:715-646-2161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002052-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice