Provider Demographics
NPI:1639184112
Name:CAMMACK, KENT ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:ALAN
Last Name:CAMMACK
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 1:625 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-1728
Mailing Address - Country:US
Mailing Address - Phone:765-832-3434
Mailing Address - Fax:765-832-7187
Practice Address - Street 1:625 ELM ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-1728
Practice Address - Country:US
Practice Address - Phone:765-832-3434
Practice Address - Fax:765-832-7187
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120087471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice