Provider Demographics
NPI:1679733265
Name:CLARK, PORTER JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:PORTER
Middle Name:JAMES
Last Name:CLARK
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 1:422 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-3716
Mailing Address - Country:US
Mailing Address - Phone:620-331-3580
Mailing Address - Fax:620-331-3587
Practice Address - Street 1:422 E MAIN ST
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-3716
Practice Address - Country:US
Practice Address - Phone:620-331-3580
Practice Address - Fax:620-331-3587
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS43201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice