Provider Demographics
NPI:1982769154
Name:LICKING VALLEY DENTAL ASSOCIATES PSC
Entity Type:Organization
Organization Name:LICKING VALLEY DENTAL ASSOCIATES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:CLYDE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-234-3323
Mailing Address - Street 1:114 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CYNTHIANA
Mailing Address - State:KY
Mailing Address - Zip Code:41031-1521
Mailing Address - Country:US
Mailing Address - Phone:859-234-3323
Mailing Address - Fax:859-234-3332
Practice Address - Street 1:114 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CYNTHIANA
Practice Address - State:KY
Practice Address - Zip Code:41031-1521
Practice Address - Country:US
Practice Address - Phone:859-234-3323
Practice Address - Fax:859-234-3332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1538232194Medicare UPIN
KY1457375594Medicare UPIN