Provider Demographics
NPI:1033396999
Name:CLEMENZA, JOHN W (DMD, MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:CLEMENZA
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3041 INNOVATION WAY
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-7905
Mailing Address - Country:US
Mailing Address - Phone:724-981-8884
Mailing Address - Fax:
Practice Address - Street 1:3041 INNOVATION WAY
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-7905
Practice Address - Country:US
Practice Address - Phone:724-981-8884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-027772-L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA014446XNVMedicare PIN