Provider Demographics
NPI:1053832907
Name:CLARK, DAVID STEPHEN (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:STEPHEN
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 1:5810 E SKELLY DR STE 1800
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6434
Mailing Address - Country:US
Mailing Address - Phone:918-998-0996
Mailing Address - Fax:
Practice Address - Street 1:2909 AZALEA PARK DR
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-2283
Practice Address - Country:US
Practice Address - Phone:918-682-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK69771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice