Healthcare Provider Details

I. General information

NPI: 1073679866
Provider Name (Legal Business Name): CLINTON DENTAL CLINIC,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 03/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S WASHINGTON ST
CLINTON KY
42031-1440
US

IV. Provider business mailing address

PO BOX 217
CLINTON KY
42031-0217
US

V. Phone/Fax

Practice location:
  • Phone: 270-653-4600
  • Fax: 270-653-2778
Mailing address:
  • Phone: 270-653-4600
  • Fax: 270-653-2778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4384
License Number StateKY

VIII. Authorized Official

Name: DR. RICKEY ALLAN CANTY
Title or Position: OWNER-DENTIST
Credential: D.M.D.
Phone: 270-653-4600