Provider Demographics
NPI:1396879037
Name:CLEGG, STEPHEN CONNELL (DDS)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:CONNELL
Last Name:CLEGG
Suffix:
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 1:1026 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-5002
Mailing Address - Country:US
Mailing Address - Phone:830-997-3399
Mailing Address - Fax:830-990-9200
Practice Address - Street 1:1026 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-5002
Practice Address - Country:US
Practice Address - Phone:830-997-3399
Practice Address - Fax:830-990-9200
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6662840001Medicare NSC