Provider Demographics
NPI:1003220203
Name:CLARK, SHANE THOMAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:THOMAS
Last Name:CLARK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 OAKLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2721
Mailing Address - Country:US
Mailing Address - Phone:512-689-8382
Mailing Address - Fax:
Practice Address - Street 1:2800 COORS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1204
Practice Address - Country:US
Practice Address - Phone:505-352-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2015-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD41001223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics