Provider Demographics
NPI:1083958433
Name:CLIFFORD, CASEY WOOD (DDS)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:WOOD
Last Name:CLIFFORD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 E 100 S
Mailing Address - Street 2:SUITE E
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1455
Mailing Address - Country:US
Mailing Address - Phone:801-355-5657
Mailing Address - Fax:
Practice Address - Street 1:928 E 100 S
Practice Address - Street 2:SUITE E
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1455
Practice Address - Country:US
Practice Address - Phone:801-355-5657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8448000-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist