Healthcare Provider Details

I. General information

NPI: 1952306425
Provider Name (Legal Business Name): KENAN DAVID CLINTON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 POPLAR AVE SUITE 260
MEMPHIS TN
38119-4823
US

IV. Provider business mailing address

6401 POPLAR AVE SUITE 260
MEMPHIS TN
38119-4823
US

V. Phone/Fax

Practice location:
  • Phone: 901-682-8847
  • Fax: 901-682-8891
Mailing address:
  • Phone: 901-682-8847
  • Fax: 901-682-8891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number8189
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: