Provider Demographics
NPI:1992715288
Name:STREET, CHAD CLIFTON (DMD, MD)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:CLIFTON
Last Name:STREET
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 LORAINE ST
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-3757
Mailing Address - Country:US
Mailing Address - Phone:606-432-9639
Mailing Address - Fax:606-432-9689
Practice Address - Street 1:129 LORAINE ST
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3757
Practice Address - Country:US
Practice Address - Phone:606-432-9639
Practice Address - Fax:606-432-9689
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY71031223S0112X
KY38532204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64068414Medicaid
KY60002300Medicaid
KY1204662OtherCHA PROVIDER #