MEDICARE: DR. LUCIOUS HENRY CLEMONS D.D.S.

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	122300000X	Dentist	0401003703	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	FORMERLY 54-109-4553	OTHER	VA	FORMERLY L.HENRY CLEMONS D.D.S. PC ( NO LONGER CORPORATION) AND NO CORP TAX ID
2	0401003703	OTHER	VA	VIRGINIA STATE BOARD OF DENTISTRY LICENSE

General Provider Information

NPI Number	:	1134385149
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LUCIOUS HENRY CLEMONS D.D.S.

Provider Business Mailing Address
First Line	:	9700 FORT KING RD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23229-3842
Country	:	US
Telephone Number	:	804-270-5033
Fax Number	:

Provider Business Practice Location Address
First Line	:	9700 FORT KING RD
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23229-3842
Country	:	US
Telephone Number	:	804-270-5033
Fax Number	:

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

Provider Enumeration Date	:	07/30/2008
Last Update Date	:	07/30/2008

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