Provider Demographics
NPI:1659442325
Name:CLANCY, CHRISTOPHER KEVIN (DMD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:KEVIN
Last Name:CLANCY
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 1:299 LINCOLN ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-3609
Mailing Address - Country:US
Mailing Address - Phone:508-329-1212
Mailing Address - Fax:
Practice Address - Street 1:299 LINCOLN ST
Practice Address - Street 2:SUITE 204
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3609
Practice Address - Country:US
Practice Address - Phone:508-852-0021
Practice Address - Fax:508-852-0031
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA202051223S0112X
FLDN163051223S0112X
PADS0352681223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX20080Medicare ID - Type UnspecifiedMEDICARE NUMBER