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General NPI Number Information
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NPI Number | 1639568603
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Entity Type | Organization
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Legal Business Name | KENNETH C. CLARK DDS,MS
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Dates
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Enumeration Date | 01/14/2015
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Last Update Date | 01/14/2015
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Provider Practice Location Address
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Address Line | 2524 HILLSIDE HEIGHTS DR
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City | GREEN BAY
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State | WI
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Zip | 54311-6777
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Country | US
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Telephone | 920-246-6118
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Fax |
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Provider Business Mailing Address
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Address Line | 2524 HILLSIDE HEIGHTS DR
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City | GREEN BAY
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State | WI
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Zip | 54311-6777
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Country | US
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Telephone | 920-246-6118
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Fax |
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Authorized Official
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Title or Position | ENDODONTIST
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Name | DR. KENNETH CHARLES CLARK
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Credential | D.D.S., M.S.
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Telephone | 920-246-6118
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 3707-15
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License Number State | WI
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