Provider Demographics
NPI:1568597631
Name:CLIFTON, JACK DIETERICH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:DIETERICH
Last Name:CLIFTON
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:PO BOX 709
Mailing Address - Street 2:
Mailing Address - City:STEVENSON
Mailing Address - State:WA
Mailing Address - Zip Code:98648-0709
Mailing Address - Country:US
Mailing Address - Phone:509-427-8605
Mailing Address - Fax:509-427-5711
Practice Address - Street 1:52 NW SECOND STREET
Practice Address - Street 2:
Practice Address - City:STEVENSON
Practice Address - State:WA
Practice Address - Zip Code:98648
Practice Address - Country:US
Practice Address - Phone:509-427-8605
Practice Address - Fax:509-427-5711
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice