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General NPI Number Information
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NPI Number | 1467697003
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Entity Type | Organization
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Legal Business Name | CLINT FULKS, INC.
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Dates
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Enumeration Date | 12/11/2008
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Last Update Date | 06/01/2023
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Provider Practice Location Address
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Address Line | 1200 FERGUSON DR SUITE 4
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City | BENTON
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State | AR
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Zip | 72015-3503
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Country | US
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Telephone | 501-778-9222
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Fax | 501-778-9223
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Provider Business Mailing Address
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Address Line | 3316 HIGHWAY 5 N SUITE 1
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City | BRYANT
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State | AR
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Zip | 72019-9031
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Country | US
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Telephone | 501-847-6453
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Fax | 501-847-6460
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Authorized Official
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Title or Position | OWNER
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Name | DR. CLINT ALLEN FULKS
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Credential | DDS
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Telephone | 501-350-4564
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 3521
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License Number State | AR
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