Provider Demographics
NPI:1083756274
Name:CLARK, BRIAN EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:EDWARD
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 1:5544 TURNEY RD
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-3780
Mailing Address - Country:US
Mailing Address - Phone:216-581-8931
Mailing Address - Fax:216-581-8931
Practice Address - Street 1:5544 TURNEY RD
Practice Address - Street 2:
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-3780
Practice Address - Country:US
Practice Address - Phone:216-581-8931
Practice Address - Fax:216-581-8931
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH15130122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0310621Medicaid