Provider Demographics
NPI:1689994923
Name:CLARK, PAUL KENNETH III (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:KENNETH
Last Name:CLARK
Suffix:III
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 LOCUST ST N STE 103
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-6375
Mailing Address - Country:US
Mailing Address - Phone:208-831-2900
Mailing Address - Fax:
Practice Address - Street 1:1502 LOCUST ST N STE 103
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6375
Practice Address - Country:US
Practice Address - Phone:208-831-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-09
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5108-OS1223S0112X
UT7829973-99221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery