Provider Demographics
NPI:1053594796
Name:CLARK, CELIA KEISLING (RDH)
Entity type:Individual
Prefix:MRS
First Name:CELIA
Middle Name:KEISLING
Last Name:CLARK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 CAMINO SAN JUAN
Mailing Address - Street 2:
Mailing Address - City:RIDGWAY
Mailing Address - State:CO
Mailing Address - Zip Code:81432-9637
Mailing Address - Country:US
Mailing Address - Phone:970-626-4396
Mailing Address - Fax:
Practice Address - Street 1:55 CAMINO SAN JUAN
Practice Address - Street 2:
Practice Address - City:RIDGWAY
Practice Address - State:CO
Practice Address - Zip Code:81432-9637
Practice Address - Country:US
Practice Address - Phone:970-626-4396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-17
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2506124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist