Provider Demographics
NPI:1730262684
Name:CLARK, KEITH LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:LEE
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3101 RIO GRANDE CIR
Mailing Address - Street 2:
Mailing Address - City:CRESSON
Mailing Address - State:TX
Mailing Address - Zip Code:76035-4193
Mailing Address - Country:US
Mailing Address - Phone:318-455-1121
Mailing Address - Fax:
Practice Address - Street 1:1116 N MEADOWS DR
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1717
Practice Address - Country:US
Practice Address - Phone:817-573-4746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX195581223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR225558608Medicaid