Provider Demographics
NPI:1821653056
Name:CLANAMAN, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:CLANAMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 DAYLILLY WAY
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-7766
Mailing Address - Country:US
Mailing Address - Phone:215-200-0474
Mailing Address - Fax:
Practice Address - Street 1:17 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1218
Practice Address - Country:US
Practice Address - Phone:201-996-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI028504001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program