Provider Demographics
NPI:1164675252
Name:CLARK III, KIRKLAND WOODRUFF (DMD)
Entity Type:Individual
Prefix:DR
First Name:KIRKLAND
Middle Name:WOODRUFF
Last Name:CLARK III
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8810 HIGHWAY 9
Mailing Address - Street 2:PO BOX 38
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-8718
Mailing Address - Country:US
Mailing Address - Phone:864-592-1647
Mailing Address - Fax:864-592-0630
Practice Address - Street 1:8810 HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:INMAN
Practice Address - State:SC
Practice Address - Zip Code:29349-8718
Practice Address - Country:US
Practice Address - Phone:864-592-1647
Practice Address - Fax:864-592-0630
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC4457122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist