Provider Demographics
NPI:1154908341
Name:CLEMENTINO DE SA, ANNY MICHELINE
Entity type:Individual
Prefix:DR
First Name:ANNY
Middle Name:MICHELINE
Last Name:CLEMENTINO DE SA
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 1:2565 UNIVERSITY PKWY APT 4405
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-2979
Mailing Address - Country:US
Mailing Address - Phone:919-152-5022
Mailing Address - Fax:
Practice Address - Street 1:3920 BEE RIDGE RD STE C
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-1207
Practice Address - Country:US
Practice Address - Phone:941-306-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL256551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice