Healthcare Provider Details

I. General information

NPI: 1477688547
Provider Name (Legal Business Name): JACK D CLIFTON, DDS, PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 NW SECOND STREET
STEVENSON WA
98648-0709
US

IV. Provider business mailing address

PO BOX 709
STEVENSON WA
98648-0709
US

V. Phone/Fax

Practice location:
  • Phone: 509-427-8605
  • Fax: 509-427-5711
Mailing address:
  • Phone: 509-427-8605
  • Fax: 509-427-5711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number6156
License Number StateWA

VIII. Authorized Official

Name: DR. JACK DIETERICH CLIFTON
Title or Position: GENERAL DENTIST
Credential: DDS
Phone: 509-427-8605