Healthcare Provider Details

I. General information

NPI: 1447675673
Provider Name (Legal Business Name): M CLEMENTE DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 W RIDGEWOOD AVE
RIDGEWOOD NJ
07450-3197
US

IV. Provider business mailing address

60 W RIDGEWOOD AVE
RIDGEWOOD NJ
07450-3197
US

V. Phone/Fax

Practice location:
  • Phone: 201-447-2888
  • Fax: 201-447-3834
Mailing address:
  • Phone: 201-447-2888
  • Fax: 201-447-3834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9757
License Number StateNJ

VIII. Authorized Official

Name: LAUREN ROBERTSON
Title or Position: FINANCIAL COORDINATOR
Credential:
Phone: 201-447-2888