Provider Demographics
NPI:1811338650
Name:GORE, CLINTON K (DDS)
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:K
Last Name:GORE
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 1:10767 E TRAVERSE HWY
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-6219
Mailing Address - Country:US
Mailing Address - Phone:231-947-3476
Mailing Address - Fax:231-947-0146
Practice Address - Street 1:10767 E TRAVERSE HWY
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6219
Practice Address - Country:US
Practice Address - Phone:231-947-3476
Practice Address - Fax:231-947-0146
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901011808122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist