Provider Demographics
NPI:1043220684
Name:CLARK, BRUCE R (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:R
Last Name:CLARK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 STOVER ST
Mailing Address - Street 2:BLDG E-102
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525
Mailing Address - Country:US
Mailing Address - Phone:970-498-8607
Mailing Address - Fax:970-498-8607
Practice Address - Street 1:2550 STOVER ST
Practice Address - Street 2:BLDG E-102
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525
Practice Address - Country:US
Practice Address - Phone:970-498-8607
Practice Address - Fax:970-498-8607
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO70281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice