Provider Demographics
NPI:1831126309
Name:CLEMONS, EDWARD JACOB JR (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JACOB
Last Name:CLEMONS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:5011 SOUTHPARK DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7738
Mailing Address - Country:US
Mailing Address - Phone:919-361-9700
Mailing Address - Fax:919-361-9747
Practice Address - Street 1:5011 SOUTHPARK DR
Practice Address - Street 2:SUITE 110
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-7738
Practice Address - Country:US
Practice Address - Phone:919-361-9700
Practice Address - Fax:919-361-9747
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC55811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC91662OtherBCBS
NC8991662Medicaid