Provider Demographics
NPI:1376853929
Name:CLINTON, EDNA L (DMD)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:L
Last Name:CLINTON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 S US 301
Mailing Address - Street 2:
Mailing Address - City:SUMTERVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:33585-5141
Mailing Address - Country:US
Mailing Address - Phone:352-793-5900
Mailing Address - Fax:352-793-8050
Practice Address - Street 1:7205 SE MARICAMP RD
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34472-2105
Practice Address - Country:US
Practice Address - Phone:352-680-0324
Practice Address - Fax:352-680-0173
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN198781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL631KPOtherBCBS
FL006788500Medicaid