Provider Demographics
NPI:1952504219
Name:CLEMOW, JUSTIN BICE (DMD, MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:BICE
Last Name:CLEMOW
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W STRUB RD STE A
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-5390
Mailing Address - Country:US
Mailing Address - Phone:419-627-8131
Mailing Address - Fax:
Practice Address - Street 1:2500 W STRUB RD STE A
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5390
Practice Address - Country:US
Practice Address - Phone:419-627-8131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0239151223S0112X
FLDN18025204E00000X
OH30.023915204E00000X
OH35.121660204E00000X
MADN1856941204E00000X
MA264666204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty