Provider Demographics
NPI:1457558082
Name:MCQUEEN, CLINT BRANDON (DMD)
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:BRANDON
Last Name:MCQUEEN
Suffix:
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 1:118 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-2318
Mailing Address - Country:US
Mailing Address - Phone:606-574-9000
Mailing Address - Fax:606-574-9001
Practice Address - Street 1:118 S 1ST ST
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-2318
Practice Address - Country:US
Practice Address - Phone:606-574-9000
Practice Address - Fax:606-574-9001
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY85131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100041230Medicaid