Healthcare Provider Details

I. General information

NPI: 1891217295
Provider Name (Legal Business Name): CLARK HEPWORTH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 07/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4965 W COMMERCE ST
SAN ANTONIO TX
78237-1508
US

IV. Provider business mailing address

4502 HAWTHORN WOODS
SAN ANTONIO TX
78249-1486
US

V. Phone/Fax

Practice location:
  • Phone: 210-702-3206
  • Fax:
Mailing address:
  • Phone: 913-530-8581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number33238
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: