Basic Information
| Provider Information | |||||||||
| NPI: | 1699723494 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN W. CLEMENZA, DMD, MD ORAL AND FACIAL SURGICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3041 INNOVATION WAY | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249818884 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3041 INNOVATION WAY | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 16148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249818884 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 03/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | CLEMENZA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7249818884 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.M.D., M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 974553 | 01 | PA | BC/ BS | OTHER |