Provider Demographics
NPI:1629563531
Name:COVERT, CLINTON MATTHEW
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:MATTHEW
Last Name:COVERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10115 OAK MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:SUNMAN
Mailing Address - State:IN
Mailing Address - Zip Code:47041-9120
Mailing Address - Country:US
Mailing Address - Phone:513-370-0237
Mailing Address - Fax:
Practice Address - Street 1:1019 W EADS PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-1162
Practice Address - Country:US
Practice Address - Phone:812-496-5828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012965A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist