Individual
DR. CLARK U KNOWLTON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Contact information
Practice address
543 W GABLE ST, MERIDIAN, ID 83646-6355
(310) 562-8760
Mailing address
111 E 210TH ST, BRONX, NY 10467-2401
(718) 920-4321
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
DD5108
NM
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
D-5193-OR
ID
390200000X
Student in an Organized Health Care Education/Training Program
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—
Other
Enumeration date
06/10/2016
Last updated
05/05/2021
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