Provider Demographics
NPI:1487769055
Name:AVERY, CLARENCE RENSHAW (DDS)
Entity type:Individual
Prefix:DR
First Name:CLARENCE
Middle Name:RENSHAW
Last Name:AVERY
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:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39568-0405
Mailing Address - Country:US
Mailing Address - Phone:228-762-9123
Mailing Address - Fax:228-762-9123
Practice Address - Street 1:5106 TELEPHONE RD
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-1120
Practice Address - Country:US
Practice Address - Phone:228-762-9123
Practice Address - Fax:228-762-9123
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1819-78122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist