Provider Demographics
NPI:1194825299
Name:MUSGRAVE, CLYDE ARMSTRONG (DMD)
Entity Type:Individual
Prefix:PROF
First Name:CLYDE
Middle Name:ARMSTRONG
Last Name:MUSGRAVE
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 1:2925 NAIL RD E
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6620
Mailing Address - Country:US
Mailing Address - Phone:662-893-7337
Mailing Address - Fax:662-893-7881
Practice Address - Street 1:3964 GOODMAN RD E STE 128
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6494
Practice Address - Country:US
Practice Address - Phone:662-893-7337
Practice Address - Fax:662-893-7881
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3136-001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660434Medicaid