Provider Demographics
NPI:1417052945
Name:CLEMMONS, WARD WILLIAM (DDS, PA)
Entity Type:Individual
Prefix:DR
First Name:WARD
Middle Name:WILLIAM
Last Name:CLEMMONS
Suffix:
Gender:M
Credentials:DDS, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 OLD GREENWOOD RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5929
Mailing Address - Country:US
Mailing Address - Phone:479-434-6894
Mailing Address - Fax:479-434-6896
Practice Address - Street 1:3600 OLD GREENWOOD RD
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-5929
Practice Address - Country:US
Practice Address - Phone:479-434-6894
Practice Address - Fax:479-434-6896
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2820122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR2820OtherLICENSE #
AR121451608Medicaid
AR71-0751372OtherTAX ID #
OK175067Medicaid