Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 29523 | TX |
N | 1223E0200X | Endodontist | D7207 | AZ |
NPI | 1043426943 |
---|---|
Provider Name | Dr. Paul Derald Clark |
First Address | Mckinney, TX 75071-5627 |
Second Address | Mckinney, TX 75071-5627 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2007 |
Last Update Date | 15/01/2021 |