Provider Demographics
NPI:1235315771
Name:CLEMONS COSMETIC & FAMILY DENTISTRY
Entity Type:Organization
Organization Name:CLEMONS COSMETIC & FAMILY DENTISTRY
Other - Org Name:EDWARD J. CLEMONS JR., DDS, PA
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:CLEMONS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-361-9700
Mailing Address - Street 1:5011 SOUTHPARK DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7738
Mailing Address - Country:US
Mailing Address - Phone:919-361-9700
Mailing Address - Fax:919-361-9747
Practice Address - Street 1:5011 SOUTHPARK DR
Practice Address - Street 2:SUITE 110
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-7738
Practice Address - Country:US
Practice Address - Phone:919-361-9700
Practice Address - Fax:919-361-9747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5581261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC91662OtherBCBS
NC8991662Medicaid