Provider Demographics
NPI:1194902957
Name:ADDISON, CLARENCE JR (DMD)
Entity type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:
Last Name:ADDISON
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 ORCHARD RD SE STE 300
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-4900
Mailing Address - Country:US
Mailing Address - Phone:770-433-0445
Mailing Address - Fax:
Practice Address - Street 1:4045 ORCHARD RD SE STE 300
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-4900
Practice Address - Country:US
Practice Address - Phone:770-433-0445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10977122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist