Provider Demographics
NPI:1114364692
Name:CLEVIDENCE, DUSTIN S (DMD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:S
Last Name:CLEVIDENCE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 553
Mailing Address - Street 2:
Mailing Address - City:MORGANFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42437-0553
Mailing Address - Country:US
Mailing Address - Phone:270-389-0812
Mailing Address - Fax:270-389-0812
Practice Address - Street 1:1311 KIMBER LN STE 3
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-9149
Practice Address - Country:US
Practice Address - Phone:812-477-3393
Practice Address - Fax:812-479-4120
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY92921223G0001X, 122300000X
IN120119631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist