Provider Demographics
NPI:1174605901
Name:DEAN, CLARENCE (DDS)
Entity type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:
Last Name:DEAN
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 1:222 INNISBROOKE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9209
Mailing Address - Country:US
Mailing Address - Phone:317-889-1578
Mailing Address - Fax:
Practice Address - Street 1:222 INNISBROOKE AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9209
Practice Address - Country:US
Practice Address - Phone:317-889-1578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007193122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12007193AMedicaid