Provider Demographics
NPI:1396107397
Name:CLINTON ADAMS, PRISCILLA (DDS)
Entity type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:
Last Name:CLINTON ADAMS
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 1:1616 E 56TH ST UNIT 401
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-2705
Mailing Address - Country:US
Mailing Address - Phone:708-602-0017
Mailing Address - Fax:
Practice Address - Street 1:1121 W MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:708-602-0017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013039A1223G0001X
390200000X
IL0190310771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program