Provider Demographics
NPI:1033281555
Name:CLARK, HEATHER E (DMD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:E
Last Name:CLARK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 N EASTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-4717
Mailing Address - Country:US
Mailing Address - Phone:215-884-1130
Mailing Address - Fax:215-887-4407
Practice Address - Street 1:269 N EASTON RD
Practice Address - Street 2:
Practice Address - City:GLENSIDE
Practice Address - State:PA
Practice Address - Zip Code:19038-4717
Practice Address - Country:US
Practice Address - Phone:215-884-1130
Practice Address - Fax:215-887-4407
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS031551L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist