Provider Demographics
NPI:1437132305
Name:CLARKE, KELLY R (DDS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:CLARKE
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 1:2204 E 29TH AVE
Mailing Address - Street 2:STE. 208
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-3961
Mailing Address - Country:US
Mailing Address - Phone:509-535-9515
Mailing Address - Fax:
Practice Address - Street 1:2204 E 29TH AVE
Practice Address - Street 2:STE. 208
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99203-3961
Practice Address - Country:US
Practice Address - Phone:509-535-9515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD84211223G0001X
WADE000101991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR233086Medicaid