Provider Demographics
NPI:1962943001
Name:WIRE, CLINT (DDS, MS)
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:WIRE
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23505 E APPLEWAY AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-6003
Mailing Address - Country:US
Mailing Address - Phone:360-280-2385
Mailing Address - Fax:
Practice Address - Street 1:23505 E APPLEWAY AVE STE 204
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-6003
Practice Address - Country:US
Practice Address - Phone:509-892-9284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA615013881223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty