Individual
CHAD CLIFTON STREET
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD, MD
Contact information
Practice address
129 LORAINE ST, PIKEVILLE, KY 41501-3757
(606) 432-9639
(606) 432-9689
Mailing address
129 LORAINE ST, PIKEVILLE, KY 41501-3757
(606) 432-9639
(606) 432-9689
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
7103
KY
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
38532
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1204662
CHA PROVIDER #
KY
05
—
60002300
—
KY
05
—
64068414
—
KY
Enumeration date
08/09/2006
Last updated
06/11/2014
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