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General NPI Number Information
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NPI Number | 1689994923
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Entity Type | Individual
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Provider Name | PAUL KENNETH CLARK III D.M.D, M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/09/2010
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Last Update Date | 11/15/2022
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Provider Practice Location Address
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Address Line | 1502 LOCUST ST N STE 103
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City | TWIN FALLS
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State | ID
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Zip | 83301-6375
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Country | US
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Telephone | 208-831-2900
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Fax |
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Provider Business Mailing Address
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Address Line | 1502 LOCUST ST N STE 103
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City | TWIN FALLS
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State | ID
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Zip | 83301-6375
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Country | US
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Telephone | 208-831-2900
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | D-5108-OS
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 7829973-9922
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License Number State | UT
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