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General NPI Number Information
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NPI Number | 1982769154
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Entity Type | Organization
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Legal Business Name | LICKING VALLEY DENTAL ASSOCIATES PSC
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Dates
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Enumeration Date | 12/27/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 114 S MAIN ST
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City | CYNTHIANA
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State | KY
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Zip | 41031-1521
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Country | US
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Telephone | 859-234-3323
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Fax | 859-234-3332
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Provider Business Mailing Address
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Address Line | 114 S MAIN ST
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City | CYNTHIANA
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State | KY
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Zip | 41031-1521
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Country | US
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Telephone | 859-234-3323
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Fax | 859-234-3332
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JAMES STEPHEN CLYDE
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Credential | DMD
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Telephone | 859-234-3323
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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 | 4932
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License Number State | KY
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