Provider Demographics
NPI:1730064114
Name:CLARK, KATHERINE ANNE (DDS)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:CLARK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E GLADE RD APT 9201
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-7392
Mailing Address - Country:US
Mailing Address - Phone:225-241-2856
Mailing Address - Fax:
Practice Address - Street 1:2246 JACKSBORO HWY STE 112
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-2363
Practice Address - Country:US
Practice Address - Phone:817-529-1799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41822122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist