Provider Demographics
NPI:1356133870
Name:CLARK ORAL & FACIAL SURGERY - BURLEY
Entity type:Organization
Organization Name:CLARK ORAL & FACIAL SURGERY - BURLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DURELLA
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-831-2900
Mailing Address - Street 1:1404 POMERELLE AVE STE A2
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2013
Mailing Address - Country:US
Mailing Address - Phone:208-831-2901
Mailing Address - Fax:208-736-6249
Practice Address - Street 1:1404 POMERELLE AVE STE A2
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2013
Practice Address - Country:US
Practice Address - Phone:208-831-2901
Practice Address - Fax:208-736-6249
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLARK ORAL & FACIAL SURGERY - BURLEY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery