Provider Demographics
NPI:1356456651
Name:KLEMENT, BETTY DERRICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:BETTY
Middle Name:DERRICK
Last Name:KLEMENT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 KINGSLEY AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5180
Mailing Address - Country:US
Mailing Address - Phone:904-272-7277
Mailing Address - Fax:
Practice Address - Street 1:2140 KINGSLEY AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5180
Practice Address - Country:US
Practice Address - Phone:904-272-7277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN102441223G0001X
GADN0093281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice