MEDICARE: DR. DALE GLEN CLAUSSEN DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	19 15844	IL

General Provider Information

NPI Number	:	1780687293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALE GLEN CLAUSSEN DMD

Provider Business Mailing Address
First Line	:	620 SAINT LOUIS ST
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-1504
Country	:	US
Telephone Number	:	618-656-0201
Fax Number	:

Provider Business Practice Location Address
First Line	:	620 SAINT LOUIS ST
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-1504
Country	:	US
Telephone Number	:	618-656-0201
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2005
Last Update Date	:	07/08/2007

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