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General NPI Number Information
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NPI Number | 1851441802
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Entity Type | Individual
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Provider Name | KELLEY 'CORKY' DEATON III DMD
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Gender | Male
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Dates
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Enumeration Date | 01/11/2007
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Last Update Date | 03/11/2015
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Provider Practice Location Address
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Address Line | 359 S 4TH ST SUITE C
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City | DANVILLE
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State | KY
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Zip | 40422-2078
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Country | US
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Telephone | 859-236-5703
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Fax | 859-936-1916
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Provider Business Mailing Address
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Address Line | 359 S 4TH ST SUITE C
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City | DANVILLE
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State | KY
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Zip | 40422-2078
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Country | US
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Telephone | 859-236-5703
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Fax | 859-936-1916
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5843
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5843
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License Number State | KY
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