Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 6921 | KS |
NPI | 1013019694 |
---|---|
Provider Name | Mark Alan Clemens |
First Address | Leavenworth, KS 66048-1957 |
Second Address | Leavenworth, KS 66048-1957 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2006 |
Last Update Date | 08/07/2007 |