Provider Demographics
NPI:1013018803
Name:CLARK, DAVID BRYCE (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRYCE
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 S MILLER ST
Mailing Address - Street 2:P.O. BOX 234
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-2949
Mailing Address - Country:US
Mailing Address - Phone:317-392-6166
Mailing Address - Fax:317-392-6196
Practice Address - Street 1:1530 S MILLER ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-2949
Practice Address - Country:US
Practice Address - Phone:317-392-6166
Practice Address - Fax:317-392-6196
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008231A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics