MEDICARE: CLEMENT RAINBOW MODERN DENTISTRY, PC

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
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1477295368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEMENT RAINBOW MODERN DENTISTRY, PC

Provider Business Mailing Address
First Line	:	PO BOX 920050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75392-0050
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	303-952-0852

Provider Business Practice Location Address
First Line	:	3675 S RAINBOW BLVD STE 105
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-1059
Country	:	US
Telephone Number	:	702-602-2196
Fax Number	:	702-444-2325

Authorized Official
Title or Position	:	OWNER/DMD
Name	:	JENNIFER CLEMENT
Credential	:
Telephone Number	:	701-601-2196

Provider Enumeration Date	:	04/11/2022
Last Update Date	:	02/21/2023

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