Provider Demographics
NPI:1083824478
Name:CLARK, ERIC JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:JOSEPH
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 1:500 N BROADWAY
Mailing Address - Street 2:#4
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92225-1279
Mailing Address - Country:US
Mailing Address - Phone:760-922-0266
Mailing Address - Fax:760-922-1066
Practice Address - Street 1:500 N BROADWAY
Practice Address - Street 2:#4
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-1279
Practice Address - Country:US
Practice Address - Phone:760-922-0266
Practice Address - Fax:760-922-1066
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38407122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB3840701OtherDENTIST