Provider Demographics
NPI:1689728909
Name:COLVILLE, CLARK D (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:CLARK
Middle Name:D
Last Name:COLVILLE
Suffix:
Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:205 S STATE HIGHWAY 46
Mailing Address - Street 2:
Mailing Address - City:SEGUIN
Mailing Address - State:TX
Mailing Address - Zip Code:78155-7504
Mailing Address - Country:US
Mailing Address - Phone:830-372-9811
Mailing Address - Fax:830-303-0149
Practice Address - Street 1:205 S STATE HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-7504
Practice Address - Country:US
Practice Address - Phone:830-372-9811
Practice Address - Fax:830-303-0149
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX159021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics