Provider Demographics
NPI:1831738087
Name:CLARK, KENDRA NICOLE (DMD)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:NICOLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 MARILLA ST APT 4310
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-5959
Mailing Address - Country:US
Mailing Address - Phone:601-213-4389
Mailing Address - Fax:
Practice Address - Street 1:3880 HULEN ST STE 310
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7274
Practice Address - Country:US
Practice Address - Phone:817-737-7668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-04
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34365122300000X, 1223E0200X
MS3992-18122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist