MEDICARE: MATTHEW HENRY MCCLEMENT DMD

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	APP-000364488	OH
2	122300000X	Dentist	D010919	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	APP-000364488	OTHER	OH	THE OHIO STATE UNIVERSITY

General Provider Information

NPI Number	:	1710502679
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW HENRY MCCLEMENT DMD

Provider Business Mailing Address
First Line	:	1157 S CRISMON RD STE 103
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85208-2661
Country	:	US
Telephone Number	:	520-220-5266
Fax Number	:	520-357-9030

Provider Business Practice Location Address
First Line	:	1157 S CRISMON RD STE 103
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85208-2661
Country	:	US
Telephone Number	:	520-220-5266
Fax Number	:	520-357-9030

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

Provider Enumeration Date	:	06/16/2020
Last Update Date	:	07/09/2024

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