Provider Demographics
NPI:1366127607
Name:KIERNAN, MARY CLAIRE (DDS)
Entity type:Individual
Prefix:
First Name:MARY CLAIRE
Middle Name:
Last Name:KIERNAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MARYCLAIRE
Other - Middle Name:
Other - Last Name:KIERNAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:5724 GIDDINGS AVE
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-5000
Mailing Address - Country:US
Mailing Address - Phone:630-956-2064
Mailing Address - Fax:
Practice Address - Street 1:8920 W CONNELL CT SUITE 310
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-266-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.033087122300000X
WI6001312-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty