Individual
DR. KELLEY 'CORKY' DEATON III
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
359 S 4TH ST, SUITE C, DANVILLE, KY 40422-2078
(859) 236-5703
(859) 936-1916
Mailing address
359 S 4TH ST, SUITE C, DANVILLE, KY 40422-2078
(859) 236-5703
(859) 936-1916
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
5843
KY
1223G0001X
General Practice Dentistry
Primary
5843
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
45601382
EPSDT DENTAL ID
KY
05
—
60058435
—
KY
01
—
61-1180059
TAX ID
KY
Enumeration date
01/11/2007
Last updated
03/11/2015
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