Provider Demographics
NPI:1689752602
Name:CLOUGH-PERIN, KATIE MARIE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATIE
Middle Name:MARIE
Last Name:CLOUGH-PERIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KATIE
Other - Middle Name:MARIE
Other - Last Name:CLOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:26624 CHISHOLM TRL
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1700
Mailing Address - Country:US
Mailing Address - Phone:315-276-5851
Mailing Address - Fax:
Practice Address - Street 1:33054 NYS RTE 26
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-8600
Practice Address - Country:US
Practice Address - Phone:315-493-9393
Practice Address - Fax:315-493-9394
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052833-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice