Provider Demographics
NPI:1811577455
Name:CEMENTUM LLC
Entity Type:Organization
Organization Name:CEMENTUM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BATEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:936-657-0110
Mailing Address - Street 1:3205 N UNIVERSITY DR STE B
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2683
Mailing Address - Country:US
Mailing Address - Phone:936-657-0110
Mailing Address - Fax:
Practice Address - Street 1:3205 N UNIVERSITY DR STE B
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2683
Practice Address - Country:US
Practice Address - Phone:936-657-0110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1801104427Medicaid