Provider Demographics
NPI:1700215175
Name:KRISTIN D. CLARK DDS, MS, PA
Entity Type:Organization
Organization Name:KRISTIN D. CLARK DDS, MS, PA
Other - Org Name:CLARK ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS, PA
Authorized Official - Phone:501-758-4112
Mailing Address - Street 1:5503 JOHN F. KENNEDY BLVD.
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116
Mailing Address - Country:US
Mailing Address - Phone:501-758-4112
Mailing Address - Fax:501-758-4117
Practice Address - Street 1:5503 JOHN F. KENNEDY BLVD.
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116
Practice Address - Country:US
Practice Address - Phone:501-758-4112
Practice Address - Fax:501-758-4117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-06
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200527631Medicaid