Provider Demographics
NPI:1588746218
Name:MCCLINTOCK, KELLY L (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 CHAGRIN RD STE 11
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44023-4702
Mailing Address - Country:US
Mailing Address - Phone:440-543-5020
Mailing Address - Fax:
Practice Address - Street 1:8401 CHAGRIN RD STE 11
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44023-4702
Practice Address - Country:US
Practice Address - Phone:440-543-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH212561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice