Provider Demographics
NPI:1699073247
Name:CLEMENTE, MARISSA CHEVAUGHN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARISSA
Middle Name:CHEVAUGHN
Last Name:CLEMENTE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 ROUTE 304
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-2919
Mailing Address - Country:US
Mailing Address - Phone:845-638-6646
Mailing Address - Fax:
Practice Address - Street 1:603 ROUTE 304
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-2919
Practice Address - Country:US
Practice Address - Phone:845-638-6646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052943-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice