Provider Demographics
NPI:1386093219
Name:KNOWLTON, CLARK U (DDS)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:U
Last Name:KNOWLTON
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 1:111 E 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2401
Mailing Address - Country:US
Mailing Address - Phone:718-920-4321
Mailing Address - Fax:
Practice Address - Street 1:543 W GABLE ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6355
Practice Address - Country:US
Practice Address - Phone:310-562-8760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD5108122300000X
390200000X
IDD-5193-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program