Provider Demographics
NPI:1982798336
Name:CLEMENS, GARY ROGER (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ROGER
Last Name:CLEMENS
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 1:3340 S. OAK PARK AVE.
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402
Mailing Address - Country:US
Mailing Address - Phone:708-795-1255
Mailing Address - Fax:708-795-1215
Practice Address - Street 1:3340 S. OAK PARK AVE.
Practice Address - Street 2:SUITE 301
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402
Practice Address - Country:US
Practice Address - Phone:708-795-1255
Practice Address - Fax:708-795-1215
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice