Provider Demographics
NPI:1316955107
Name:CLEMETSON, JONATHAN CHRISTOPHER (D D S)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:CHRISTOPHER
Last Name:CLEMETSON
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7416 CORONADO AVE
Mailing Address - Street 2:APT. 6
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-5834
Mailing Address - Country:US
Mailing Address - Phone:214-324-5468
Mailing Address - Fax:
Practice Address - Street 1:1700 PACIFIC AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75201-4617
Practice Address - Country:US
Practice Address - Phone:214-651-0005
Practice Address - Fax:214-651-1419
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163530201Medicaid
TXV06701Medicare UPIN
TX163530201Medicaid