Healthcare Provider Details

I. General information

NPI: 1497130512
Provider Name (Legal Business Name): JACQUELINE CLARY D.M.D, M.S.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 LAKELAND DRIVE
CHIPPEWA WI
54701
US

IV. Provider business mailing address

1885 EL PASEO ST APT 32307
HOUSTON TX
77054-3051
US

V. Phone/Fax

Practice location:
  • Phone: 715-738-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number30763
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: