Provider Demographics
NPI:1851441802
Name:DEATON, KELLEY 'CORKY' III (DMD)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:'CORKY'
Last Name:DEATON
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 S 4TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2078
Mailing Address - Country:US
Mailing Address - Phone:859-236-5703
Mailing Address - Fax:859-936-1916
Practice Address - Street 1:359 S 4TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2078
Practice Address - Country:US
Practice Address - Phone:859-236-5703
Practice Address - Fax:859-936-1916
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY58431223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY45601382OtherEPSDT DENTAL ID
KY61-1180059OtherTAX ID
KY60058435Medicaid