Provider Demographics
NPI:1043426943
Name:CLARK, PAUL DERALD (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DERALD
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5913 VIRGINIA PKWY STE 400
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-5627
Mailing Address - Country:US
Mailing Address - Phone:972-547-0202
Mailing Address - Fax:972-547-0212
Practice Address - Street 1:5913 VIRGINIA PKWY STE 400
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-5627
Practice Address - Country:US
Practice Address - Phone:972-547-0202
Practice Address - Fax:972-547-0212
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD72071223E0200X
TX295231223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics