Provider Demographics
NPI:1265520829
Name:CLARKSON, KELLY L (DDS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:CLARKSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3066 E COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78220-1013
Mailing Address - Country:US
Mailing Address - Phone:210-233-7062
Mailing Address - Fax:210-434-1704
Practice Address - Street 1:3066 E COMMERCE ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78220-1013
Practice Address - Country:US
Practice Address - Phone:210-233-7000
Practice Address - Fax:210-277-6387
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE66641223G0001X
TX250291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice