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General NPI Number Information
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NPI Number | 1730262684
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Entity Type | Individual
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Provider Name | KEITH LEE CLARK D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 03/02/2023
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Provider Practice Location Address
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Address Line | 1116 N MEADOWS DR
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City | GRANBURY
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State | TX
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Zip | 76048-1717
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Country | US
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Telephone | 817-573-4746
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Fax |
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Provider Business Mailing Address
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Address Line | 3101 RIO GRANDE CIR
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City | CRESSON
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State | TX
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Zip | 76035-4193
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Country | US
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Telephone | 318-455-1121
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 19558
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License Number State | TX
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