Healthcare Provider Details

I. General information

NPI: 1659442325
Provider Name (Legal Business Name): CHRISTOPHER KEVIN CLANCY D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 LINCOLN ST SUITE 204
WORCESTER MA
01605-3609
US

IV. Provider business mailing address

299 LINCOLN ST SUITE 204
WORCESTER MA
01605-3609
US

V. Phone/Fax

Practice location:
  • Phone: 508-852-0021
  • Fax: 508-852-0031
Mailing address:
  • Phone: 508-329-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number20205
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN16305
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS035268
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: