Provider Demographics
NPI:1003977620
Name:CLARK, RDEAN
Entity Type:Individual
Prefix:
First Name:RDEAN
Middle Name:
Last Name:CLARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 EAST UNIVERSITY PARKWAY
Mailing Address - Street 2:SUITE A24
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058
Mailing Address - Country:US
Mailing Address - Phone:801-225-3300
Mailing Address - Fax:
Practice Address - Street 1:575 EAST UNIVERSITY PARKWAY
Practice Address - Street 2:SUITE A24
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058
Practice Address - Country:US
Practice Address - Phone:801-225-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTY762421223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics