Provider Demographics
NPI:1811937808
Name:CLEMENCE, KEITH DOUGLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:DOUGLAS
Last Name:CLEMENCE
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 1:5751 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:HALES CORNERS
Mailing Address - State:WI
Mailing Address - Zip Code:53130-1940
Mailing Address - Country:US
Mailing Address - Phone:414-425-0120
Mailing Address - Fax:414-425-0978
Practice Address - Street 1:5751 S 108TH ST
Practice Address - Street 2:
Practice Address - City:HALES CORNERS
Practice Address - State:WI
Practice Address - Zip Code:53130-1940
Practice Address - Country:US
Practice Address - Phone:414-425-0120
Practice Address - Fax:414-425-0978
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50015581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice