Healthcare Provider Details

I. General information

NPI: 1568063576
Provider Name (Legal Business Name): CLOVIS ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E 21ST ST STE A
CLOVIS NM
88101-4492
US

IV. Provider business mailing address

7701 SW 45TH AVE
AMARILLO TX
79119-6299
US

V. Phone/Fax

Practice location:
  • Phone: 575-763-1101
  • Fax:
Mailing address:
  • Phone: 806-355-9732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN KYLE SPARKMAN
Title or Position: OWNER
Credential: DDS, MS
Phone: 806-355-9732