Provider Demographics
NPI:1962600361
Name:MASSIE, CLARA JO (DMD)
Entity type:Individual
Prefix:DR
First Name:CLARA
Middle Name:JO
Last Name:MASSIE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 E LINCOLN TRAIL BLVD
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-1253
Mailing Address - Country:US
Mailing Address - Phone:270-351-5858
Mailing Address - Fax:
Practice Address - Street 1:169 E LINCOLN TRAIL BLVD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-1253
Practice Address - Country:US
Practice Address - Phone:270-351-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY52201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice