Provider Demographics
NPI:1093948267
Name:KVISTAD, CLARK KENNETH (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:KENNETH
Last Name:KVISTAD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21807 76TH AVE W
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7938
Mailing Address - Country:US
Mailing Address - Phone:425-775-2002
Mailing Address - Fax:
Practice Address - Street 1:21807 76TH AVE W
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7938
Practice Address - Country:US
Practice Address - Phone:425-775-2002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA35801223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics