Provider Demographics
NPI:1497912927
Name:FULKS, CLINT ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:ALLEN
Last Name:FULKS
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 1:3305 HIGHWAY 5 N STE 1
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72019-9031
Mailing Address - Country:US
Mailing Address - Phone:501-847-6453
Mailing Address - Fax:
Practice Address - Street 1:3305 HIGHWAY 5 N STE 1
Practice Address - Street 2:
Practice Address - City:BRYANT
Practice Address - State:AR
Practice Address - Zip Code:72019-9031
Practice Address - Country:US
Practice Address - Phone:501-847-6453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR35211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR00001871870OtherUCCI
AR169089608Medicaid