Provider Demographics
NPI:1386758936
Name:CLARK, PAUL M JR (DDS)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:M
Last Name:CLARK
Suffix:JR
Gender:M
Credentials:DDS
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Mailing Address - Street 1:2120 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE D
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3351
Mailing Address - Country:US
Mailing Address - Phone:318-687-9800
Mailing Address - Fax:318-687-4752
Practice Address - Street 1:2120 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE D
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3351
Practice Address - Country:US
Practice Address - Phone:318-687-9800
Practice Address - Fax:318-687-4752
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA24321223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA58046Medicare ID - Type Unspecified
LAT19750Medicare UPIN