Provider Demographics
NPI:1336523364
Name:VANESA G CLEMENTS DDS PC
Entity Type:Organization
Organization Name:VANESA G CLEMENTS DDS PC
Other - Org Name:LEGACY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-986-2222
Mailing Address - Street 1:2200 BOCA CHICA BLVD
Mailing Address - Street 2:#138
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-2212
Mailing Address - Country:US
Mailing Address - Phone:956-986-2222
Mailing Address - Fax:956-986-2223
Practice Address - Street 1:2200 BOCA CHICA BLVD
Practice Address - Street 2:#138
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-2212
Practice Address - Country:US
Practice Address - Phone:956-986-2222
Practice Address - Fax:956-986-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX240251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193080207Medicaid
TX1700047271OtherNPI