Provider Demographics
NPI:1639678337
Name:CLARKE L SHORT DDS LLC
Entity Type:Organization
Organization Name:CLARKE L SHORT DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CLARKE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-850-7280
Mailing Address - Street 1:347 W IDAHO AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2344
Mailing Address - Country:US
Mailing Address - Phone:541-889-8837
Mailing Address - Fax:
Practice Address - Street 1:347 WEST IDAHO AVENUE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-9791
Practice Address - Country:US
Practice Address - Phone:541-889-8837
Practice Address - Fax:541-889-8991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD10763122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty