Provider Demographics
NPI:1245367150
Name:CLEMONS, WILSON BRYAN II (DDS)
Entity type:Individual
Prefix:DR
First Name:WILSON
Middle Name:BRYAN
Last Name:CLEMONS
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 ARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-6604
Mailing Address - Country:US
Mailing Address - Phone:319-338-9219
Mailing Address - Fax:319-338-7265
Practice Address - Street 1:1041 ARTHUR ST
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-6604
Practice Address - Country:US
Practice Address - Phone:319-338-9219
Practice Address - Fax:319-338-7265
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA54291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1437247202OtherNPI FOR CORPORATION
IA0132258Medicaid